ANNEX
B
CASHLESS
EXERCISE FORM
(To
be executed upon partial or full
exercise
of Warrants pursuant to Section 1.3 of the Warrant)
The
undersigned hereby irrevocably elects to surrender ____________ shares of Common
Stock of LaPolla Industries, Inc. purchasable under the Warrants for such shares
of Common Stock issuable in exchange therefor pursuant to the Cashless Exercise
provisions of the within Warrants, as provided for in Section 1.3 of such
Warrant.
Please
issue a certificate or certificates for such Common Stock in the name of, and
pay cash for fractional shares in the name of:
(Please
print name, address, and social security number/tax identification
number:)
and,
if
said number of shares of Common Stock shall not be all the shares of Common
Stock purchasable thereunder, that a new Warrant for the balance remaining
of
the shares of Common Stock purchasable under the within Warrants be registered
in the name of the undersigned Holder or its transferee as below indicated
and
delivered to the address stated below.
| Name
of Warrant Holder |
|
|
or
transferee:
|
|
|
|
(Please
Print)
|
|
|
NOTICE:
|
The
signature on this form must correspond with the name as written upon
the
face of this Warrant in every particular, without alteration or
enlargement or any change
whatsoever.
|
