Delaware | | | 46-5696597 |
(State or other jurisdiction of incorporation or organization) | | | (I.R.S. Employer Identification Number) |
Andrew D. Hoffman Wilson Sonsini Goodrich & Rosati 650 Page Mill Road Palo Alto, CA 94304 (650) 493-9300 | | | Sandra A. Gardiner Chief Financial Officer, Executive Vice President of Finance and Administration, Secretary and Treasurer Pulse Biosciences, Inc. 3957 Point Eden Way Hayward, California 94545 (510) 906-4600 |
Large Accelerated filer | | | ☐ | | | Accelerated filer | | | ☒ |
Non-accelerated filer | | | ☐ | | | Smaller reporting company | | | ☒ |
| | | | Emerging growth company | | | ☒ |
Title of Each Class of Securities to be Registered(1) | | | Amount To Be Registered | | | Proposed Maximum Offering Price Per Unit or Share | | | Proposed Maximum Aggregate Offering Price | | | Amount of Registration Fee |
Common Stock, $0.001 par value per share | | | — | | | — | | | $30,000,000(3) | | | $3,894.00(2) |
Subscription rights to purchase common stock | | | — | | | — | | | — | | | —(3) |
(1) | This registration statement relates to: (a) non-transferable subscription rights to purchase the registrant’s common stock, which subscription rights are to be issued to holders of the registrant’s common stock on a pro rata basis without consideration, and (b) the shares of the registrant’s common stock issuable upon the exercise of such non-transferable subscription rights pursuant to the rights offering. |
(2) | Calculated pursuant to Rule 457(o) based on an estimate of the proposed maximum offering price. The actual number of subscription rights and shares of the registrant’s common stock to be issued in connection with the rights offering will be determined based on the market price of the registrant’s common stock at a future date. |
(3) | The subscription rights are being issued without consideration. Pursuant to Rule 457(g), no separate registration fee is payable with respect to the subscription rights being offered hereby since the subscription rights are being registered in the same registration statement as the securities to be offered pursuant thereto. |
Q: | What is the rights offering? |
A: | We are distributing to you, at no charge, one non-transferable subscription right for each share of our common stock that you owned as of 5:00 p.m., Eastern Time, on [•], 2020, either as a holder of record or, in the case of shares held of record by custodian banks, brokers, dealers or other nominees on your behalf, as a beneficial owner of such shares. |
Q: | Why are we conducting the rights offering? |
A: | The purpose of this rights offering is to raise equity capital in a cost-effective manner that provides all of our existing stockholders the opportunity to participate. We are conducting the rights offering to provide for our general working capital purposes, including the ongoing investment in current and future clinical and pre-clinical studies evaluating the safety and efficacy of Pulse Biosciences’ proprietary NPS technology, the development and enhancement of Pulse Biosciences’ CellFX System, obtaining regulatory clearance for our CellFX System, sales and marketing activities and general corporate operations. We may also use a portion of the net proceeds from this offering to acquire or invest in complementary business, technologies, product candidates or other intellectual property, although we have no present commitments or agreements to do so. For a detailed discussion, see “Use of Proceeds” beginning on page 26. |
Q: | How was the subscription price determined? |
A: | In determining the subscription price, our board of directors, with the advice and input of management and advisors, considered a number of factors, including: the likely cost of capital from other sources, the price at which our stockholders might be willing to participate in the rights offering, historical and current trading prices for our common stock, our need for liquidity and capital and the desire to provide an opportunity to our stockholders to participate in the rights offering on a pro rata basis. In conjunction with its review of these factors, our board of directors also reviewed a range of subscription prices in various prior rights offerings of public companies. The subscription price is not necessarily related to our book value, net worth or any other established criteria of value and may or may not be considered the fair value of our common stock to be offered in the rights offering. We cannot give any assurance that our common shares will trade at or above the subscription price in any given time period. You should not consider the subscription price as an indication of value of us or our common stock. You should obtain a current quote for our common stock before exercising your subscription rights and make your own assessment of our business and financial condition, our prospects for the future, and the terms of the rights offering. |
Q: | Why did our board of directors elect to price the rights offering at the lesser of the Initial Price and the Alternate Price? |
A: | Our board of directors elected to price the rights offering at the lesser of the Initial Price and the Alternate Price to attempt to protect stockholders from any decline in the price of the Company’s common stock which may occur after the commencement of the rights offering and prior to the Expiration Date. While there is no guarantee that this mechanism will sufficiently protect stockholders that exercise their rights (see “Risk Factors” below), our board of directors and management wanted to encourage participation in the offering and strike what they believe to be a fair balance between the capital needs of the Company and the fair value of its common stock sold to the stockholders in this offering. |
Q: | Because the final subscription price may not be determined until the Expiration Date, how much money should I send to the subscription agent if I want to exercise my rights? |
A: | For purposes of initially exercising your rights, you should assume that the subscription price will equal the Initial Price of $[•] per share. Accordingly, for each right that you would like to exercise, including any rights that you would like the opportunity to exercise pursuant to the over-subscription right, you should send $[•] per share. For assistance you may contact the information agent, Broadridge Corporate Issuer Solutions, Inc., toll free at 1-888-789-8409 or by e-mail at shareholder@broadridge.com. |
Q: | What happens if the final subscription price is less than the Initial Price? |
A: | If, on the Expiration Date, the Alternate Price is lower than the Initial Price, any Excess Subscription Amounts paid by a subscriber will be put towards the purchase of additional shares in the rights offering. For example, assume that the initial subscription price is $5.00 per share. If you want to exercise your rights to purchase 100 shares, you will promptly send payment to the subscription agent in the amount of $500. If the final subscription price decreases to $4.00 per share, you will receive 125 shares rather than 100 shares and no cash back. Detailed instructions to exercise your rights, including regarding payment of the subscription price, are also included on your rights certificate. For assistance you may contact the information agent, Broadridge Corporate Issuer Solutions, Inc., toll free at 1-888-789-8409 or by e-mail at shareholder@broadridge.com. |
Q: | What is the basic subscription right? |
A: | Each subscription right gives our stockholders the right to purchase [•] shares of Pulse Biosciences’ common stock at the Initial Price, which shall be payable in cash and subject to the limits described below. To the extent that the Alternate Price is lower than the Initial Price, we will issue additional shares in the rights offering. We have granted to you, as a stockholder of record as of 5:00 p.m., Eastern Time, on the record date, one subscription right for each share of our common stock you owned at that time. For example, if you owned 100 shares of our common stock as of 5:00 p.m., Eastern Time, on the record date, you would have received 100 subscription rights and would have the right to purchase [•] shares of common stock at the Initial Price subject to certain limitations. You may exercise all or a portion of your basic subscription rights or you may choose not to exercise any subscription rights at all. However, if you exercise fewer than all of your basic subscription rights, you will not be entitled to purchase any additional shares pursuant to the over-subscription right. |
Q: | What is the over-subscription right? |
A: | We do not expect all of our stockholders to exercise all of their basic subscription rights. The over-subscription right provides stockholders that exercise all of their basic subscription rights the opportunity to purchase the shares that are not purchased by other stockholders. If you fully exercise your basic subscription right, the over-subscription right of each right entitles you to subscribe for additional shares of our common stock unclaimed by other holders of rights in this rights offering at the same subscription price per share. If an insufficient number of shares is available to fully satisfy all over-subscription right requests, the available shares will be distributed proportionately among rights holders who exercise their over-subscription right based on the number of shares each rights holder subscribed for under the basic subscription right. The proration process will be repeated until all common shares have been allocated or all over-subscription exercises have been fulfilled, whichever occurs earlier. |
Q: | Who will receive subscription rights? |
A: | Holders of our common stock will receive one non-transferable subscription right for each share of common stock owned as of [•], 2020, the record date. |
Q: | How many shares may I purchase if I exercise my subscription rights? |
A: | You will receive one non-transferable subscription right for each share of our common stock that you owned on [•], 2020, the record date. Each subscription right evidences a right to purchase [•] shares of our common stock at the Initial Price, which shall be paid in cash. To the extent that the Alternate Price is lower than the Initial price, we will issue additional shares in the rights offering. You may exercise any number of your subscription rights. |
Q: | Am I required to subscribe in the rights offering? |
A: | No. |
Q: | What happens if I choose not to exercise my subscription rights? |
A: | If you choose not to exercise your subscription rights you will retain your current number of shares of common stock of Pulse Biosciences. As a result, the percentage of the common stock of Pulse Biosciences that you own will decrease and your voting rights and other rights will be diluted. |
Q: | Am I required to exercise all of the subscription rights I receive in the rights offering? |
A: | No. You may exercise any number of your subscription rights, or you may choose not to exercise any subscription rights. If you do not exercise any subscription rights, the number of shares of our common stock you own will not change; however, you will own a smaller proportional interest in us than if you had timely exercised all or a portion of your subscription rights. If you choose not to exercise your subscription rights or you exercise fewer than all of your subscription rights and other stockholders fully exercise their subscription rights or exercise a greater proportion of their subscription rights than you exercise, the percentage of our common stock owned by these other stockholders will increase relative to your ownership percentage, and your voting and other rights in us will likewise be diluted. In addition, if you do not exercise your basic subscription right in full, you will not be entitled to participate in the over-subscription right. |
Q: | If I am a holder of stock options or warrants, may I participate in the rights offering? |
A: | No. Holders of stock options or warrants on the record date will not be entitled to participate in the rights offering, except to the extent they hold shares of our common stock on the record date. |
Q: | Will the equity awards of our employees, officers and directors automatically convert into common stock in connection with the rights offering? |
A: | Holders of our equity awards, including outstanding stock options and restricted stock units, will not receive rights in the rights offering in connection with such equity awards, but will receive subscription rights in connection with any shares of our common stock held as of the record date. |
Q: | How soon must I act to exercise my subscription rights? |
A: | If you received a rights certificate and elect to exercise any or all of your subscription rights, the subscription agent must receive your completed and signed rights certificate and payment (and your payment must clear) prior to the expiration of the rights offering, which is [•], 2020, at 5:00 p.m., Eastern Time. If you hold your shares in the name of a custodian bank, broker, dealer or other nominee, your nominee may establish a deadline prior to 5:00 p.m., Eastern Time, on [•], 2020 by which you must provide it with your instructions to exercise |
Q: | Does Pulse Biosciences need to achieve a minimum participation level in order to complete the rights offering? |
A: | No. We may choose to consummate, amend, extend or terminate the rights offering regardless of the number of shares actually purchased. |
Q: | Can Pulse Biosciences terminate the rights offering? |
A: | Yes. Our board of directors may decide to terminate the rights offering at any time prior to the expiration of the rights offering, for any reason. If we cancel the rights offering, any money received from subscribing stockholders will be refunded as soon as practicable, without interest or a deduction on any payments refunded to you under the rights offering. See “The Rights Offering — Expiration of the Rights Offering and Extensions, Amendments and Termination” beginning on page 32. |
Q: | May I transfer my subscription rights if I do not want to purchase any shares? |
A: | No. Should you choose not to exercise your rights, you may not sell, give away or otherwise transfer your rights. However, rights will be transferable as required by operation of law, for example, upon the death of the recipient. |
Q: | When will the rights offering expire? |
A: | The subscription rights will expire and will have no value, if not exercised prior thereto, at 5:00 p.m., Eastern Time, on [•], 2020, unless we decide to extend the rights offering Expiration Date until some later time or terminate it earlier. See “The Rights Offering — Expiration of the Rights Offering and Extensions, Amendments and Termination” beginning on page 32. The subscription agent must actually receive all required documents and payments in cash, as provide herein, before the Expiration Date. There is no maximum duration for the rights offering. |
Q: | Is there a guaranteed delivery period? |
A: | No. There is no guaranteed delivery period in connection with this rights offering, so you must ensure that you properly complete all required steps prior to 5:00 p.m., Eastern Time, on [•], 2020, unless we decide to extend the rights offering Expiration Date until some later time or terminate it earlier. |
Q: | How do I exercise my subscription rights if I own shares in certificate form? |
A: | You may exercise your subscription rights by properly completing and executing your rights certificate and delivering it, together in full with the subscription price for each share of common stock you subscribe for, to the subscription agent on or prior to the Expiration Date. If you use mail, we recommend that you use insured, registered mail, return receipt requested. |
Q: | What form of payment is required to purchase the shares of our common stock? |
A: | As described in the instructions accompanying the rights certificate, you must timely pay the full subscription price for the full number of shares of Common Stock you wish to acquire under your subscription rights at the Initial Price by delivering to Broadridge Corporate Issuer Solutions, Inc., the subscription agent for this rights offering, a certified check, bank draft, cashier’s check, personal check that clears before the Expiration Date, money order, or wire transfer of funds. |
Q: | What should I do if I want to participate in the rights offering but my shares are held in the name of my custodian bank, broker, dealer or other nominee? |
A: | If you hold our common stock through a custodian bank, broker, dealer or other nominee, we will ask your custodian bank, broker, dealer or other nominee to notify you of the rights offering. If you wish to exercise your rights, you will need to have your custodian bank, broker, dealer or other nominee act for you. To indicate your decision, you should complete and return to your custodian bank, broker, dealer or other nominee the form entitled “Beneficial Owner Election Form” substantially in the form accompanying this prospectus. You should receive this form from your custodian bank, broker, dealer or other nominee with the other rights offering materials. You should contact your custodian bank, broker, dealer or other nominee if you believe you are entitled to participate in the rights offering but you have not received this form. |
Q: | What should I do if I want to participate in the rights offering, but I am a stockholder with a foreign address or a stockholder with an Army Post Office or Fleet Post Office address? |
A: | The subscription agent will not mail rights certificates to you if you are a stockholder whose address is outside the United States or if you have an Army Post Office or a Fleet Post Office address. To exercise your rights, you must notify the subscription agent prior to 11:00 a.m., Eastern Time, at least three (3) business days prior to the Expiration Date, and establish to the satisfaction of the subscription agent that it is permitted to exercise your subscription rights under applicable law. If you do not follow these procedures by such time, your rights will expire and will have no value. |
Q: | Will I be charged a sales commission or a fee if I exercise my subscription rights? |
A: | We will not charge a brokerage commission or a fee to rights holders for exercising their subscription rights. However, if you exercise your subscription rights through a custodian bank, broker, dealer or nominee, you will be responsible for any fees charged by your custodian bank, broker, dealer or nominee. |
Q: | Are there any conditions to my right to exercise my subscription rights? |
A: | Yes. We may terminate the rights offering, in whole or in part, if at any time before completion of the rights offering there is any judgment, order, decree, injunction, statute, law or regulation entered, enacted, amended or held to be applicable to the rights offering that in the sole judgment of our board of directors would or might make the rights offering or its completion, whether in whole or in part, illegal or otherwise restrict or prohibit completion of the rights offering. See “The Rights Offering — Conditions to the Rights Offering” beginning on page 32. |
Q: | Has the board of directors made a recommendation regarding the rights offering? |
A: | Neither the Company, nor our board of directors is making any recommendation as to whether or not you should exercise your subscription rights. You are urged to make your decision based on your own assessment of the rights offering, after considering all of the information herein, including the “Risk Factors” beginning on page 17 of this prospectus, and of your best interests. |
Q: | Have any directors, officers, and/or stockholders agreed to exercise their rights? |
A: | All holders of our common stock as of the record date for the rights offering will receive, at no charge, the non-transferable subscription rights to purchase shares of our common stock as described in this prospectus. To the extent that our directors and officers held shares of our common stock (including shares of restricted common stock) as of the record date, they will receive the subscription rights and, while they are under no obligation to do so, will be entitled to participate in the rights offering. |
Q: | May stockholders in all states participate in the rights offering? |
A: | Although we intend to distribute the rights to all stockholders, we reserve the right in some states to require stockholders, if they wish to participate, to state and agree upon exercise of their respective rights that they are acquiring the shares for investment purposes only, and that they have no present intention to resell or transfer any shares acquired. Our securities are not being offered in any jurisdiction where the offer is not permitted under applicable local laws. |
Q: | Are there risks in exercising my subscription rights? |
A: | The exercise of your subscription rights involves significant risks. Exercising your rights means buying additional shares of our common stock and should be considered as carefully as you would consider any other equity investment. Among other things, you should carefully consider the risks described under the heading “Risk Factors,” beginning on page 17. |
Q: | How many shares of our common stock will be outstanding after the rights offering? |
A: | The number of shares of our common stock that will be outstanding after the rights offering will depend on the number of shares that are purchased in the rights offering. Assuming no additional shares of common stock are issued by us prior to consummation of the rights offering and assuming all offered shares are sold in the rights offering at the Initial Price, we will issue approximately [•] shares of common stock. In that case, we will have approximately [•] shares of common stock outstanding after the rights offering. This would represent an increase of approximately [•]% in the number of outstanding shares of common stock. To the extent that the Alternate Price is lower than the Initial Price, we will issue additional shares in the rights offering and the number of shares of common stock outstanding after the rights offering will be higher. |
Q: | What will be the proceeds of the rights offering? |
A: | If all rights are exercised, we will receive gross proceeds of approximately $30 million before expenses, as provided herein. We are offering shares in the rights offering with no minimum purchase requirement. As a result, there is no assurance we will be able to sell all or any of the shares being offered, and it is not likely that all of our stockholders will participate in the rights offering. |
Q: | After I exercise my rights, can I change my mind and cancel my purchase? |
A: | No. Once you exercise and send in your subscription rights certificate and subscription payment, as provided herein, you cannot revoke the exercise of your subscription rights, even if you later learn information about Pulse Biosciences that you consider to be unfavorable. You should not exercise your subscription rights unless you are certain that you wish to purchase additional shares of our common stock at the Initial Price. See “The Rights Offering — No Revocation or Change” beginning on page 36. |
Q: | What are the material U.S. Federal income tax consequences of exercising my subscription rights? |
A: | Although the authorities governing transactions such as this rights offering are complex and unclear in certain respects, we believe and intend to take the position that the distribution of subscription rights to a holder with |
Q: | If the rights offering is not completed, for any reason, will my subscription payment be refunded to me? |
A: | Yes. The subscription agent will hold all funds it receives in a segregated bank account until the rights offering is completed. If the rights offering is not completed, for any reason, any money received from subscribing stockholders will be refunded in the form which paid as soon as practicable, without interest or deduction. If your shares are held in the name of a custodian bank, broker, dealer or other nominee, it may take longer for you to receive the refund of your subscription payment than if you were a record holder of your shares because the subscription agent will return payments through the record holder of your shares. |
Q: | Will I receive interest on any funds I deposit with the subscription agent? |
A: | No. You will not be entitled to any interest on any funds that are deposited with the subscription agent pending completion or cancellation of the rights offering. If the rights offering is cancelled for any reason, the subscription agent will return this money to subscribers, without interest or penalty, as soon as practicable. |
Q: | If I exercise my subscription rights, when will I receive shares of common stock I purchased in the rights offering? |
A: | We will issue those shares to you in book-entry, or uncertificated, form of our common stock purchased in the rights offering as soon as practicable after the expiration of the rights offering and after all pro rata allocations and adjustments have been completed. We will not be able to calculate the number of shares to be issued to each exercising holder until after the Expiration Date of the rights offering. |
Q: | When can I sell the shares of common stock I receive upon exercise of the subscription rights? |
A: | If you exercise your subscription rights, you will be able to resell the shares of common stock purchased by exercising your subscription rights once your account has been credited with those shares, provided you are not otherwise restricted from selling the shares (for example, because you are an insider or affiliate of the Company or because you possess material nonpublic information about the Company). Although we will endeavor to issue the shares as soon as practicable after completion of the rights offering, there may be a delay between the Expiration Date of the rights offering and the time that the shares are issued due to factors such as the time required to complete all necessary calculations. In addition, we cannot assure you that, following the exercise of your subscription rights, you will be able to sell the shares purchased in the rights offering at a price equal to or greater than the subscription price. |
Q: | To whom should I send my forms and payment? |
A: | If your shares are held in the name of a custodian bank, broker, dealer or other nominee, the nominee will notify you of the rights offering and provide you with the rights offering materials, including a form entitled “Beneficial Owners Election Form.” You should send the Beneficial Owner Election form and payment, as provided therein, to the nominee, at the deadline that your nominee sets which may be earlier than the expiration of the rights offering. You should contact your custodian bank, broker, dealer or other nominee if you believe you are entitled to participate in the rights offering but you have not received this form. |
By Mail: Broadridge Corporate Issuer Solutions, Inc. Attn: BCIS Re-Organization Dept. P.O. Box 1317 Brentwood, NY 11717-0718 | | | By Overnight Delivery: Broadridge Corporate Issuer Solutions, Inc. Attn: BCIS IWS 51 Mercedes Way Edgewood, NY 11717 |
Q: | What if I have other questions? |
A: | If you have other questions about the rights offering, please contact our information agent, Broadridge Corporate Issuer Solutions, Inc., toll free at 1-888-789-8409, by e-mail at shareholder@broadridge.com, or by mail at: |
• | results of clinical trials of our planned products or those of our competitors; |
• | actions by regulatory bodies, such as the FDA, that affect our business or have the effect of delaying or rejecting approval or clearance of our planned products such as the CellFX System; |
• | actual or anticipated fluctuations in our financial condition and operating results; |
• | announcements by our customers, partners or suppliers relating directly or indirectly to our products, services or technologies; |
• | announcements of technological innovations by us or our competitors; |
• | changes in laws or regulations applicable to our planned products; |
• | announcements by us or our competitors of significant acquisitions, strategic partnerships, joint ventures, capital commitments or achievement of significant milestones; |
• | additions or departures of key personnel; |
• | competition from existing products or new products that may emerge; |
• | fluctuations in the valuation of companies perceived by investors to be comparable to us; |
• | disputes or other developments related to proprietary rights, including patents, litigation matters or our ability to obtain intellectual property protection for our technologies; |
• | actual or alleged security breaches; |
• | announcements or expectations of additional financing efforts; |
• | sales of our common stock by us or our stockholders; |
• | stock price and volume fluctuations attributable to inconsistent trading volume levels of our shares; |
• | reports, guidance and ratings issued by securities or industry analysts; |
• | overall conditions in our industry and market including the impact of COVID-19; and |
• | general economic and market conditions. |
• | to elect or defeat the election of our directors; |
• | to amend or prevent amendment of our certificate of incorporation or bylaws; |
• | to effect or prevent a merger, sale of assets or other corporate transaction; and |
• | to control the outcome of any other matter submitted to our stockholders for vote. |
• | authorize our board of directors to issue, without further action by the stockholders, up to 50,000,000 shares of preferred stock and up to approximately 500,000,000 shares of authorized but unissued shares of common stock; |
• | require that any action to be taken by our stockholders be effected at a duly called annual or special meeting and not by written consent; |
• | specify that special meetings of our stockholders can be called only by our board of directors, the chairman of our board of directors, any of our officers, or any stockholder holding at least fifteen percent (15%) of the voting power of the capital stock issued and outstanding and entitled to vote; |
• | establish an advance notice procedure for stockholder approvals to be brought before an annual meeting of our stockholders, including proposed nominations of persons for election to our board of directors; |
• | the requirement for the affirmative vote of holders of at least 66 2/3% of the voting power of all the then outstanding shares of our voting stock, voting together as a single class, to amend provisions of our certificate of incorporation or our bylaws; |
• | the ability of our board of directors by majority vote, to amend the bylaws; and |
• | provide that vacancies on our board of directors may be filled only by a majority of directors then in office, even though less than a quorum. |
• | restricting dividends on the common stock; |
• | diluting the voting power of the common stock; |
• | impairing the liquidation rights of the common stock; or |
• | delaying or preventing changes in control or management of our company. |
• | acquisition of us by means of a tender offer; |
• | acquisition of us by means of a proxy contest or otherwise; or |
• | removal of our incumbent officers and directors. |
• | Undesignated Preferred Stock. The ability to authorize undesignated preferred stock makes it possible for our board of directors to issue one or more series of preferred stock with voting or other rights or preferences that could impede the success of any attempt to change control of our company. These and other provisions may have the effect of deferring hostile takeovers or delaying changes in control or management of our company. |
• | Stockholder Meetings. Our bylaws provide that in general a special meeting of stockholders may be called only by our board of directors, the chairman of our board of directors, any of our officers, or any stockholder holding at least fifteen percent (15%) of the voting power of the capital stock issued and outstanding and entitled to vote. |
• | Requirements for Advance Notification of Stockholder Nominations and Proposals. Our bylaws establish advance notice procedures with respect to stockholder proposals and the nomination of candidates for election as directors, other than nominations made by or at the direction of our board of directors or a committee of the board of directors. |
• | Limits on Ability of Stockholders to Act by Written Consent. We have provided in our bylaws that our stockholders may not act by written consent. This limit on the ability of our stockholders to act by written consent may lengthen the amount of time required to take stockholder actions. As a result, a holder controlling a majority of our capital stock would not be able to amend our bylaws or remove directors without holding a meeting of our stockholders called in accordance with our bylaws. |
• | Amendment of Certificate of Incorporation and Bylaws. The amendment of the above provisions of our certificate of incorporation and bylaws requires approval by holders of at least two-thirds of our outstanding capital stock entitled to vote generally in the election of directors. |
• | prior to the date of the transaction, the board of directors of the corporation approved either the business combination or the transaction which resulted in the stockholder becoming an interested stockholder; |
• | upon completion of the transaction that resulted in the stockholder becoming an interested stockholder, the interested stockholder owned at least 85% of the voting stock of the corporation outstanding at the time the transaction commenced, excluding for purposes of determining the voting stock outstanding, but not for determining the outstanding voting stock owned by the interested stockholder, (i) shares owned by persons who are directors and also officers, and (ii) shares owned by employee stock plans in which employee participants do not have the right to determine confidentially whether shares held subject to the plan will be tendered in a tender or exchange offer; or |
• | at or subsequent to the date of the transaction, the business combination is approved by the board of directors of the corporation and authorized at an annual or special meeting of stockholders, and not by written consent, by the affirmative vote of at least 66-2/3% of the outstanding voting stock which is not owned by the interested stockholder. |
Assumed subscription price per share | | | | | $[•] | |
Net tangible book value per share at December 31, 2019 | | | $0.85 | | | |
Net increase per share attributable to the rights offering | | | $[•] | | | |
Pro forma net tangible book value per share after giving effect to the rights offering | | | | | $[•] | |
Dilution in net tangible book value per share to purchasers | | | | | $[•] |
• | 3,749,186 shares of common stock subject to options outstanding as of December 31, 2019, with a weighted average exercise price of $16.18 per share; |
• | 42,500 performance stock options granted during the year ended December 31, 2019; |
• | 215,500 shares of common stock subject to options granted subsequent to December 31, 2019, with a weighted average exercise price of $5.76 per share; |
• | 167,847 shares of common stock that have been reserved for issuance upon the exercise of outstanding warrants as of December 31, 2019, with a weighted average exercise price of $4.36; |
• | 222,606 shares of our common stock subject to outstanding restricted stock units as of December 31, 2019; |
• | 998,288 shares of common stock reserved for future issuance under our 2017 Equity Incentive Plan and as of December 31, 2019 (not including 833,018 shares reserved for issuance thereunder subsequent to December 31, 2019); |
• | 78,950 shares of common stock reserved for future issuance under our 2017 Inducement Equity Incentive Plan as of December 31, 2019; and |
• | 440,195 shares of common stock reserved for future issuance under our Employee Stock Purchase Plan as of December 31, 2019. |
• | an uncertified check drawn against a U.S. bank payable to “Broadridge Corporate Issuer Solutions, Inc. (acting as Subscription Agent for Pulse Biosciences)”; |
• | a wire transfer of immediately available funds to accounts maintained by the subscription agent; |
• | a certified check, bank draft, or cashier’s check drawn against a U.S. bank payable to “Broadridge Corporate Issuer Solutions, Inc. (acting as Subscription Agent for Pulse Biosciences)”; or |
• | an U.S. Postal money order payable to “Broadridge Corporate Issuer Solutions, Inc. (acting as Subscription Agent for Pulse Biosciences)”. |
• | clearance of any uncertified check deposited by the subscription agent; |
• | receipt of collected funds wired in the subscription agent’s account; |
• | receipt by the subscription agent of any certified check, bank draft, or cashier’s check drawn upon a U.S. bank; or |
• | receipt by the subscription agent of any U.S. Postal money order. |
By mail: Broadridge Corporate Issuer Solutions, Inc. Attn: BCIS Re-Organization Dept. P.O. Box 1317 Brentwood, NY 11717-0718 | | | By overnight courier: Broadridge Corporate Issuer Solutions, Inc. Attn: BCIS IWS 51 Mercedes Way Edgewood, NY 11717 |
• | An individual who is a citizen or resident of the United States; |
• | A corporation (or entity treated as a corporation for United States federal income tax purposes) created or organized, or treated as created or organized, in or under the laws of the United States, any state thereof or the District of Columbia; |
• | An estate whose income is subject to United States federal income tax regardless of its source; or |
• | A trust (i) if a United States court can exercise primary supervision over the trust’s administration and one or more United States persons are authorized to control all substantial decisions of the trust, or (ii) that has a valid election in effect under applicable Treasury Regulations to be treated as a United States person. |
• | A holder’s tax basis in its subscription rights will depend on the relative fair market value of the subscription rights received by such holder and the common stock owned by such holder at the time the subscription rights are distributed. If either (i) the fair market value of the subscription rights on the date such subscription rights are distributed is equal to at least 15% of the fair market value on such date of the common stock with respect to which the subscription rights are received or (ii) the holder elects, in its United States federal income tax return for the taxable year in which the subscription rights are received, to allocate part of its tax basis in such common stock to the subscription rights, then upon exercise of the subscription rights, the holder’s tax basis in the common stock will be allocated between the common stock and the subscription rights in proportion to their respective fair market values on the date the subscription rights are distributed. If the subscription rights received by a holder have a fair market value that is less than 15% of the fair market value of the common stock owned by such holder at the time the subscription rights are distributed, the holder’s tax basis in its subscription rights will be zero unless the holder elects to allocate its adjusted tax basis in the common stock owned by such holder in the manner described in the previous sentence. The fair market value of the subscription rights on the date the subscription rights are received is uncertain, and we have not obtained, and do not intend to obtain, an appraisal of the fair market value of the subscription rights as of that date. Fair market value is defined generally as the price at which property would hypothetically change hands between a willing buyer and a willing seller, where neither is under any compulsion to buy or sell. Fair market value is a factual determination. |
• | A holder that allows the subscription rights received in the rights offering to expire will not recognize any gain or loss, and the tax basis in the common stock owned by such holder with respect to which such subscription rights were distributed will be equal to the tax basis in such common stock immediately before the receipt of the subscription rights in the rights offering. |
• | A holder will not recognize any gain or loss upon the exercise of the subscription rights received in the rights offering. The tax basis in the common stock acquired through exercise of the subscription rights will equal the sum of the subscription price for the common stock and the holder’s tax basis, if any, in the rights as described above. The holding period for the common stock acquired through exercise of the subscription rights will begin on the date the subscription rights are exercised. |
By Mail: Broadridge Corporate Issuer Solutions, Inc. Attn: BCIS Re-Organization Dept. P.O. Box 1317 Brentwood, NY 11717-0718 | | | By Overnight Delivery: Broadridge Corporate Issuer Solutions, Inc. Attn: BCIS IWS 51 Mercedes Way Edgewood, NY 11717 |
• | our Annual Report on Form 10-K for the fiscal year ended December 31, 2019, filed on March 16, 2020, as amended by our Annual Report on Form 10-K/A for the fiscal year ended December 31, 2019, filed on March 30, 2020; |
• | our Current Reports on Form 8-K filed with the SEC on February 14, 2020 (in each case, not including any information furnished under Items 2.02 or 7.01 of Form 8-K, including the related exhibits, which information is not incorporated by reference herein); and |
• | the description of our common stock contained in the Registration Statement on Form 8-A relating thereto, including any amendment or report filed for the purpose of updating such description. |
Item 14. | Other Expenses Of Issuance And Distribution. |
SEC Registration Fee | | | $3,894 |
Subscription and Information Agent Fees and Expenses | | | 12,000 |
Legal Fees and Expenses | | | 300,000 |
Accounting Fees and Expenses | | | 55,000 |
Printing and Mailing Expenses | | | 45,000 |
Miscellaneous Expenses | | | 10,106 |
Total | | | $426,000 |
Item 15. | Indemnification of Directors and Officers. |
Item 16. | Exhibits. |
| | | | Incorporation by Reference | |||||||||||
Exhibit Number | | | Exhibit Description | | | Form | | | File No. | | | Exhibit(s) | | | Filing Date |
| | Plan of Conversion of Pulse Biosciences, Inc. | | | 8-K12B | | | 001-37744 | | | 2.1 | | | June 18, 2018 | |
| | Articles of Conversion | | | 8-K12B | | | 001-37744 | | | 3.1 | | | June 18, 2018 | |
| | Certificate of Conversion | | | 8-K12B | | | 001-37744 | | | 3.2 | | | June 18, 2018 | |
| | Certificate of Incorporation of Pulse Biosciences, Inc. | | | 8-K12B | | | 001-37744 | | | 3.3 | | | June 18, 2018 | |
| | Bylaws of Pulse Biosciences, Inc. | | | 8-K12B | | | 001-37744 | | | 3.4 | | | June 18, 2018 | |
| | Specimen Common Stock Certificate | | | 8-K12B | | | 001-37744 | | | 4.1 | | | June 18, 2018 | |
| | Form of Non-Transferable Subscription Rights Certificates | | | | | | | | | |||||
| | Opinion of Wilson Sonsini Goodrich & Rosati, P.C. | | | | | | | | | |||||
| | Consent of Gumbiner Savett Inc., Independent Registered Public Accounting Firm | | | | | | | | | |||||
| | Consent of Deloitte and Touche LLP, Independent Registered Public Accounting Firm | | | | | | | | | |||||
| | Consent of Wilson Sonsini Goodrich & Rosati, P.C. (contained in Exhibit 5.1) | | | | | | | | | |||||
| | Powers of Attorney (included on the signature page to the registration statement) | | | | | | | | | |||||
| | Form of Instruction for Use of Pulse Biosciences, Inc.’s Non-Transferable Subscription Rights Certificates | | | | | | | | | |||||
| | Form of Letter to Stockholders Who are Record Holders | | | | | | | | | |||||
| | Form of Letter to Brokers and Other Nominee Holders | | | | | | | | | |||||
| | Form of Letter to Clients of Brokers and Other Nominee Holders | | | | | | | | | |||||
| | Form of Nominee Holder Certification | | | | | | | | | |||||
| | Form of Beneficial Owner Election | | | | | | | | |
* | Filed herewith |
Item 17. | Undertakings. |
(a) | The undersigned registrant hereby undertakes: |
| | PULSE BIOSCIENCES, INC. | ||||
| | | | |||
| | By: | | | /s/ Darrin R. Uecker | |
| | | | Darrin R. Uecker President and Chief Executive Officer |
Signature | | | Title | | | Date |
/s/ Darrin R. Uecker | | | President, Chief Executive Officer and Director (Principal Executive Officer) | | | April 6, 2020 |
Darrin R. Uecker | | |||||
| | | | |||
/s/ Sandra A. Gardiner | | | Chief Financial Officer, Executive Vice President of Finance and Administration, Secretary and Treasurer (Principal Financial and Accounting Officer) | | | April 6, 2020 |
Sandra A. Gardiner | | |||||
| ||||||
| | | | |||
/s/ Robert W. Duggan | | | Chairman of the Board of Directors | | | April 6, 2020 |
Robert W. Duggan | | |||||
| | | | |||
/s/ Kenneth A. Clark | | | Director | | | April 6, 2020 |
Kenneth A. Clark | | |||||
| | | | |||
/s/ Mitchell E. Levinson | | | Director | | | April 6, 2020 |
Mitchell E. Levinson | | |||||
| | | | |||
/s/ Manmeet S. Soni | | | Director | | | April 6, 2020 |
Manmeet S. Soni | | |||||
| | | | |||
/s/ Mahkam Zanganeh | | | Director | | | April 6, 2020 |
Mahkam Zanganeh | |
| | ||
President and Chief Executive Officer | | | Secretary |
If delivering by hand or overnight courier: | | | If delivering by first class mail: |
| | ||
Broadridge Corporate Issuer Solutions, Inc. Attn: BCIS IWS 51 Mercedes Way Edgewood, NY 11717 | | | Broadridge Corporate Issuer Solutions, Inc. Attn: BCIS Re-Organization Dept. P.O. Box 1317 Brentwood, NY 11717-0718 |
(a) | EXERCISE OF SUBSCRIPTION RIGHT: |
(i) | Basic Subscription Right |
I exercise | | | | | x | | | [•] | | | = | | | | | x | | | $[•] | | | = | | | $ | |||||
| | (No. of shares owned) | | | x | | | (Initial ratio) | | | | | = | | | (No. of Basic Subscription Shares Subscribed For) | | | x | | | (Initial Price) | | | | | (Amount Enclosed) |
(ii) | Over-Subscription Right: If you fully exercise your Basic Subscription Right, above, and wish to subscribe for additional shares, you may exercise your Over-Subscription Right below. |
I exercise | | | | | x | | | $[•] | | | = | | | $ | |
| | | | | | | | | | ||||||
| | (No. of Over-Subscription Shares Subscribed For) | | | x | | | (Initial Price) | | | = | | | (Amount Enclosed) |
(b) | PAYMENT: |
| | Amount Enclosed | | | ||
Basic Subscription Right: | | | $ | | | ☐ Check or bank draft drawn on a U.S. bank, or postal or express money order payable to Broadridge Corporate Issuer Solutions, Inc., as Subscription Agent. |
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Over-Subscription Right: | | | $ | | | ☐ Wire transfer directly to the escrow account maintained by Broadridge Corporate Issuer Solutions, Inc., as Subscription Agent. |
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Total Amount Enclosed: | | | $ | | | |
| | |
(c) | SIGNATURE(S): |
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Signature(s) of Subscriber(s) | | | Date | | | Daytime Telephone Number(s) |
| | | | | | ||||
Name(s) | | | Full Title | | | Taxpayer ID # or Social Security # | | | Date |
(a) To be completed ONLY if the book-entry representing the Common Stock is to be issued in a name other than that of the registered holder. (See the Instructions.) DO NOT FORGET TO COMPLETE THE GUARANTEE OF SIGNATURE(S) SECTION BELOW. | | | (b) To be completed ONLY if the book-entry representing the Common Stock is to be issued to an address other than that shown on the front of this certificate. (See the Instructions.) DO NOT FORGET TO COMPLETE THE GUARANTEE OF SIGNATURE(S) SECTION BELOW. |
Print Full Name: | | | | | | | Print Full Name: | | | |||
Print Full Address: | | | | | | | Print Full Address: | | | |||
Taxpayer ID # or Social Security #: | | | | | | | Taxpayer ID # or Social Security #: | | |
Signature Guaranteed: | | | | | ||
| | (Name of Bank or Form) | | |
By: | | | | | ||
| | (Signature of Officer) | | |
1. | the Rights, when issued, will be valid and binding obligations of the Company, enforceable against the Company in accordance with their terms; and |
2. | the Shares, when issued, delivered and paid for in accordance upon due exercise of the Rights as contemplated in the Prospectus, will be validly issued, fully paid and non-assessable. |
| | Very truly yours, | |
| | ||
| | /s/ Wilson Sonsini Goodrich & Rosati | |
| | ||
| | WILSON SONSINI GOODRICH & ROSATI Professional Corporation |
1. | Method of Subscription—Exercise of Subscription Rights. |
• | uncertified check drawn against a U.S. bank payable to “Broadridge Corporate Issuer Solutions, Inc. (acting as Subscription Agent for Pulse Biosciences)”; |
• | wire transfer of immediately available funds to accounts maintained by the Subscription Agent for purposes of accepting subscription in the rights offering at: |
| Beneficiary Account Name: Broadridge Corporate Issuer Solutions Account Number: 4124218686 ABA/Routing number: 121000248 Bank: Wells Fargo 420 Montgomery Street San Francisco, CA 94104 United States For Further Credit: Pulse Biosciences, Inc. Account Number: 4396288102 | |
• | a certified check, bank draft, or cashier’s check drawn against a U.S. bank payable to “Broadridge Corporate Issuer Solutions, Inc. (acting as Subscription Agent for Pulse Biosciences)”; or |
• | U.S. Postal money order payable to “Broadridge Corporate Issuer Solutions, Inc. (acting as Subscription Agent for Pulse Biosciences)”. |
If delivering by hand or overnight courier: Broadridge Corporate Issuer Solutions, Inc. Attn: BCIS IWS 51 Mercedes Way Edgewood, NY 11717 | | | If delivering by first class mail: Broadridge Corporate Issuer Solutions, Inc. Attn: BCIS Re-Organization Dept. P.O. Box 1317 Brentwood, NY 11717-0718 |
2. | Issuance of Common Stock. |
(a) | Basic Subscription Right. As soon as practicable following the Expiration Time and the valid exercise of the Subscription Rights, we will issue to each exercising Subscription Rights holder shares in book-entry, or uncertificated, form representing shares of Common Stock purchased pursuant to the Basic Subscription Right. |
(b) | Over-Subscription Right. As soon as practicable following the Expiration Time and after all prorations and adjustments contemplated by the terms of the rights offering have been effected, we will issue to each Rights holder that validly exercises the Over-Subscription Right shares in book-entry, or uncertificated, form representing the number of shares of Common Stock, if any, allocated to such Rights holder pursuant to the Over-Subscription Right. |
(c) | Excess Cash Payments. As soon as practicable following the Expiration Time and after all prorations and adjustments contemplated by the terms of the rights offering have been effected, any excess subscription payments received in payment of the Initial Price will be mailed by the Subscription Agent to each Subscription Rights holder, without interest. |
3. | No Sale or Transfer of Subscription Rights. |
4. | Special Provisions Relating to the Delivery of Subscription Rights through the Depository Trust Company. |
5. | Form W-9. |
• | To the extent the aggregate Initial Price of the maximum number of Unsubscribed Shares available to you pursuant to the Over-Subscription Right is less than the amount you actually paid in connection with the exercise of the Over-Subscription Right, you will be allocated only the number of Unsubscribed Shares available to you as soon as practicable after the Expiration Time, and your excess subscription payment received by the Subscription Agent will be returned, without interest, as soon as practicable. |
• | To the extent the amount you actually paid in connection with the exercise of the Over-Subscription Right is less than the aggregate Initial Price of the maximum number of Unsubscribed Shares available to you pursuant to the Over-Subscription Right; you will be allocated the number of Unsubscribed Shares for which you actually paid in connection with the Over-Subscription Right. If, on the Expiration Date, the Alternate Price is lower than the Initial Price, any Excess Subscription Amount will be put towards the purchase of additional shares in the rights offering (either towards your Basic Subscription Right, if available, or towards the Over-Subscription Right if you have already exercised your Basic Subscription Right in full). See “The Rights Offering — Subscription Rights — Over-Subscription Rights.” |
1. | Prospectus; |
2. | Non-Transferable Subscription Rights Certificate; |
3. | Instructions as to Use of Pulse Biosciences, Inc. Non-Transferable Subscription Rights Certificates; and |
4. | A return envelope addressed to Broadridge Corporate Issuer Solutions, Inc., the Subscription Agent. |
| | Very truly yours, | |
| | ||
| | Pulse Biosciences, Inc. |
• | To the extent the aggregate Initial Price of the maximum number of Unsubscribed Shares available to Recordholder pursuant to the Over-Subscription Right is less than the amount Recordholder actually paid in connection with the exercise of the Over-Subscription Right, Recordholder will be allocated only the number of Unsubscribed Shares available to Recordholder as soon as practicable after the Expiration Time, and the Recordholder’s excess subscription payment received by the Subscription Agent will be returned, without interest, as soon as practicable. |
• | To the extent the amount Recordholder actually paid in connection with the exercise of the Over-Subscription Right is less than the aggregate Initial Price of the maximum number of Unsubscribed Shares available to Recordholder pursuant to the Over-Subscription Right; Recordholder will be allocated the number of Unsubscribed Shares for which the Recordholder actually paid in connection with the Over-Subscription Right. If, on the Expiration Date, the Alternate Price is lower than the Initial Price, any Excess Subscription Amount will be put towards the purchase of additional shares in the rights offering (either towards the Recordholder’s Basic Subscription Right, if available, or towards the Over-Subscription Right if the Recordholder has already exercised its Basic Subscription Right in full). See “The Rights Offering—Subscription Rights—Over-Subscription Rights.” |
1. | Prospectus; |
2. | Instructions as to Use of Pulse Biosciences, Inc. Non-Transferable Subscription Rights Certificates; |
3. | A form of letter which may be sent to your clients for whose accounts you hold shares of our Common Stock registered in your name or the name of your nominee; |
4. | Beneficial Owner Election; |
5. | Nominee Holder Certification; and |
6. | A return envelope addressed to Broadridge Corporate Issuer Solutions, Inc., the Subscription Agent. |
| | Very truly yours, | |
| | ||
| | Pulse Biosciences, Inc. |
• | To the extent the aggregate Initial Price of the maximum number of Unsubscribed Shares available to you pursuant to the Over-Subscription Right is less than the amount you actually paid in connection with the exercise of the Over-Subscription Right, you will be allocated only the number of Unsubscribed Shares available to you as soon as practicable after the Expiration Time, and your excess subscription payment received by the Subscription Agent will be returned, without interest, as soon as practicable. |
• | To the extent the amount you actually paid in connection with the exercise of the Over-Subscription Right is less than the aggregate Initial Price of the maximum number of Unsubscribed Shares available to you pursuant to the Over-Subscription Right; you will be allocated the number of Unsubscribed Shares for which you actually paid in connection with the Over-Subscription Right. If, on the Expiration Date, the Alternate Price is lower than the Initial Price, any Excess Subscription Amount will be put towards the purchase of additional shares in the rights offering (either towards your Basic Subscription Right, if available, or towards the Over-Subscription Right if you have already exercised your Basic Subscription Right in full). See “The Rights Offering — Subscription Rights — Over-Subscription Rights.” |
| | Very truly yours, | |
| | ||
| | Pulse Biosciences, Inc. |
| | NUMBER OF SHARES OWNED ON RECORD DATE | | | NUMBER OF SHARES SUBSCRIBED FOR PURSUANT TO BASIC SUBSCRIPTION RIGHT | | | NUMBER OF SHARES SUBSCRIBED FOR PURSUANT TO OVER-SUBSCRIPTION RIGHT | |
1. | | | | | | | |||
2. | | | | | | | |||
3. | | | | | | | |||
4. | | | | | | | |||
5. | | | | | | |
By: | | | | | ||
| | Authorized Signature | | | ||
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Name: | | | | | ||
| | (Please print or type) | | | ||
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Title: | | | | | ||
| | (Please print or type) | | | ||
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Provide the following information if applicable: | | | ||||
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Depository Trust Company (“DTC”) Participant Number | | | ||||
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Participant: | | | | | ||
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By: | | | | | ||
| | Authorized Signature | | | ||
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Name: | | | | | ||
| | (Please print or type) | | | ||
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Title: | | | | | ||
| | (Please print or type) | | | ||
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DTC Subscription Confirmation Number(s) | ||||||
Box 1. | | | ☐ | | | Please DO NOT EXERCISE SUBSCRIPTION RIGHTS for shares of Common Stock. |
| | | | If you checked Box 1, please sign and date this form and mail it to your broker, custodian bank or your other nominee that holds your shares. | ||
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Box 2. | | | ☐ | | | Please EXERCISE SUBSCRIPTION RIGHTS for shares of Common Stock as set forth below. |
| | | | If you checked Box 2, please fill out the table shown below. Next, please check Box 3 and/or Box 4, as applicable, and fill out the information indicated under Box 3 and/or Box 4, as applicable. Please then sign and date this form and mail it to your broker, custodian bank or other nominee that holds your shares. | ||
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| | | | The number of Subscription Rights for which the undersigned gives instructions for exercise under the subscription privilege should not exceed the number of Subscription Rights that the undersigned is entitled to exercise. |
| | Number of Shares Owned | | | | | Initial Ratio | | | | | Number of Shares of Common Stock Subscribed For | | | | | Per Share Initial Subscription Price (the “Initial Price”) | | | | | Payment | |||||
Basic Subscription Right: | | | | | x | | | [•] | | | = | | | | | x | | | $ [•] | | | = | | | $ (Line 1) | ||
Over-Subscription Right: | | | | | | | | | | | | | x | | | $ [•] | | | = | | | $ (Line 2) | |||||
Total Payment Required: | | | | | | | | | | | | | | | | | | | $ (Sum of Lines 1 and 2) |
Box 3. | | | ☐ | | | Payment in the following amount is enclosed: $__________. |
| | | | |||
Box 4. | | | ☐ | | | Please deduct payment of $__________ from the following account maintained by you: |
| | | | The total of Box 3 and 4, together, must equal the sum of lines 1 and 2 from Box 2 above. | ||
| | | | |||
| | | | Type of Account: ____________________ Account No.: ____________________ |
• | irrevocably elect to purchase the number of shares of Common Stock indicated above upon the terms and conditions specified in the Prospectus; |
• | understands that if the [•] on 5:00 p.m., Eastern Time, on [•], 2020 (the “Alternate Price”) is lower than the Initial Price, any excess subscription amounts paid by me (us) will be put towards the purchase of additional shares in the rights offering (either towards my (our) Basic Subscription Right, if available, or towards the Over-Subscription Right if I (we) have already exercised my (our) Basic Subscription Right in full); and |
• | agree that if I (we) fail to pay for the shares of Common Stock I (we) have elected to purchase, you may exercise any remedies available to you under law. |
Name of beneficial owner(s): | | | | | ||
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Signature of beneficial owner(s): | | | | | ||
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Date: | | | | |
Name: | | | | | ||
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Capacity: | | | | | ||
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Address (including Zip Code): | | | | | ||
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Telephone Number: | | | | |