(1) |
the undersigned has exercised, on behalf of the beneficial owners thereof (which may include the undersigned), the number of Rights to purchase the number of Shares specified below pursuant to the Basic
Subscription Right (as defined in the Prospectus) and, on behalf of beneficial owners of Rights who have subscribed for the purchase of additional Shares pursuant to the Over-Subscription Right (as defined in the Prospectus), the number of
Shares specified below pursuant to the Over-Subscription Right, listing separately below each such exercised Basic Subscription Right and the corresponding Over-Subscription Right (without identifying any such beneficial owner); and
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(2) |
to the extent a beneficial owner has elected to subscribe for Shares pursuant to an Over-Subscription Right, each such beneficial owner’s Basic Subscription Right has been exercised in full.
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Number of Shares of
Common Stock Owned
on the Record Date
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Number of Shares
Subscribed
for Pursuant to the
Basic Subscription Right
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Number of Shares
Subscribed
for Pursuant to the
Over-Subscription Right
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6.
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8.
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9.
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Name of Nominee Holder
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Depository Trust Company (“DTC”) Participant Number
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By:
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Name:
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DTC Basic Subscription Confirmation Number(s)
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Title:
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Phone Number:
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Fax Number:
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Dated:
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