Nuverra Environmental Solutions, Inc. - FORM S-1/A - EX-99.4 - July 13, 2016

Attached files

file filename
S-1/A - AMENDMENT NO. 1 TO FORM S-1 - Nuverra Environmental Solutions, Inc.d187100ds1a.htm
EX-99.6 - EX-99.6 - Nuverra Environmental Solutions, Inc.d187100dex996.htm
EX-99.5 - EX-99.5 - Nuverra Environmental Solutions, Inc.d187100dex995.htm
EX-99.3 - EX-99.3 - Nuverra Environmental Solutions, Inc.d187100dex993.htm
EX-99.2 - EX-99.2 - Nuverra Environmental Solutions, Inc.d187100dex992.htm
EX-99.1 - EX-99.1 - Nuverra Environmental Solutions, Inc.d187100dex991.htm
EX-23.1 - EX-23.1 - Nuverra Environmental Solutions, Inc.d187100dex231.htm
EX-5.1 - EX-5.1 - Nuverra Environmental Solutions, Inc.d187100dex51.htm
EX-4.3 - EX-4.3 - Nuverra Environmental Solutions, Inc.d187100dex43.htm
EX-4.2 - EX-4.2 - Nuverra Environmental Solutions, Inc.d187100dex42.htm

Exhibit 99.4

NUVERRA ENVRIONMENTAL SOLUTIONS, INC.

FORM OF BENEFICIAL HOLDER ELECTION FORM

The undersigned acknowledge(s) receipt of your letter and the enclosed materials relating to the grant of non-transferable rights to purchase common stock, par value $0.001 per share, of Nuverra Envrionmental Solutions, Inc. (“Nuverra”).

I (we) hereby instruct you as follows:

(CHECK THE APPLICABLE BOXES AND PROVIDE ALL REQUIRED INFORMATION)

Box 1. ¨ Please DO NOT EXERCISE RIGHTS for shares of Common Stock.

Box 2. ¨ Please EXERCISE RIGHTS for shares of Common Stock as set forth below:

A. Number of Shares Being Purchased:                 

B. Total Subscription Price Payment Required:                 

Subscription Right

 

     NUMBER OF
RIGHTS		          RATIO          NUMBER OF
SHARES		          SUBSCRIPTION
PRICE		           PAYMENT  

Basic Subscription Rights

        X           =           X       $                     =      $                

Box 3. ¨ Payment in the following amount is enclosed.

$                

(The total of the above must equal the Total Payment Required.)

I (we) on my (our) own behalf, or on behalf of any person(s) on whose behalf, or under whose directions, I am (we are) signing this form:

 

  •  

irrevocably elect to purchase the number of shares indicated above upon the terms and conditions specified in the prospectus; and

 

  •  

agree that if I (we) fail to pay for the shares I (we) have elected to purchase, the exercise will be invalid.

 

Name of Beneficial Owner(s):

   

 

Signature of Beneficial Owner(s):

   

 

If you are signing in your capacity as a trustee, executor, administrator, guardian, attorney-in-fact, agent, officer of a corporation or another acting in a fiduciary or representative capacity, please provide the following information:

 

Name:

   

 

Capacity:

   

 

Address (including Zip Code):

   

 

  

 

Telephone Number:

   

 

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