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THE OFFER AND WITHDRAWAL RIGHTS WILL EXPIRE AT ONE MINUTE AFTER 11:59 P.M., NEW YORK CITY TIME, ON DECEMBER 11, 2023, UNLESS THE OFFER IS EXTENDED OR EARLIER TERMINATED (SUCH DATE AND TIME, AS IT MAY BE EXTENDED OR EARLIER TERMINATED, THE “EXPIRATION DATE AND TIME”).
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DESCRIPTION OF SHARES TENDERED
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Name(s) and Address(es) of
Registered Holder(s) (Please Fill in Exactly as Name(s) Appear(s) on Share Certificate(s), if applicable) (Attach Additional List, if Necessary) |
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Certificated Shares
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Book Entry
Shares Tendered |
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Share Certificate
Number(s)* |
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Shares
Represented by Share Certificate(s)* |
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Number of
Shares Tendered** |
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Total Shares
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By Mail or Overnight Courier:
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By Facsimile Transmission
(for eligible institutions only): 212-616-7610 Continental Stock Transfer & Trust Company 1 State Street, 30th Floor New York, NY 10004 Attention: Corporate Actions Department (Miromatrix) |
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Continental Stock Transfer & Trust Company
1 State Street, 30th Floor New York, NY 10004 Attention: Corporate Actions Department (Miromatrix) |
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| Name of Tendering Institution: |
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Account Number:
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| Names(s) of Registered Holder(s): |
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| Window Ticket Number (if any): |
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| Date of Execution of Notice of Guaranteed Delivery: |
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| Name of Institution that Guaranteed Delivery: |
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SPECIAL PAYMENT INSTRUCTIONS
(See Instructions 1, 6, 7 and 13) |
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| | | To be completed ONLY if the check for the Cash Consideration (less any required withholding taxes) for Shares accepted for payment is to be issued in the name of someone other than the undersigned or if Shares tendered by book-entry transfer which are not accepted for payment are to be returned by credit to an account maintained at DTC other than that designated above. | | | |||
| | | ☐ Issue check to: | | | |||
| | | Name: | | |
(Please Print)
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| | | Address: | | |
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(Zip Code)
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(Taxpayer Identification No.)
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| | | ☐ Credit Shares tendered by book-entry transfer that are not accepted for payment to the DTC account set forth below. | | | |||
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(DTC Account Number)
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SPECIAL DELIVERY INSTRUCTIONS
(See Instructions 1, 6, 7 and 13) |
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| | | To be completed ONLY if the check for the Cash Consideration (less any required withholding taxes) for Shares accepted for payment is to be mailed to the undersigned at an address other than that shown in the box titled “Description of Shares Tendered” above. | | | |||
| | | Mail check to: | | | |||
| | | Name: | | |
(Please Print)
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| | | Address: | | |
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(Zip Code)
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(Taxpayer Identification No.)
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Signature(s) of Owners
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| | Dated , 202 | | ||||||
| | Name(s) | | |
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(Please Print)
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Capacity (Full Title)
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| | Address | | |
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(Include Zip Code)
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Area Code and Telephone Number
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Authorized Signature(s)
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| | Name | | |
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Name of Firm
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| | Address | | |
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(Include Zip Code)
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Area Code and Telephone Number
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