Exhibit 4.11

 

BLACK RIDGE OIL & GAS, INC.
 
UP TO 431,819,910 SHARES OF COMMON STOCK
ISSUABLE UPON EXERCISE OF NON-TRANSFERABLE RIGHTS
TO SUBSCRIBE FOR SUCH SHARES
 
NOMINEE HOLDER CERTIFICATION

 

The undersigned, a bank, custodian bank or other nominee holder (the “Nominee Holder”) of rights (the “Subscription Rights”) to purchase shares of common stock, par value $0.001 per share (the “Shares”) of BLACK RIDGE OIL & GAS, INC. (the “Company”), pursuant to the rights offering described in the Company’s prospectus, dated August 3, 2017(the “Prospectus”), hereby certifies to the Company and Broadridge Corporate Issuer Solutions, Inc., as subscription agent for the rights offering, that the undersigned has exercised, on behalf of the beneficial owners thereof (which may include the undersigned), the Subscription Rights to subscribe for the number of Shares specified below under the subscription right, the terms of which are described further in the Prospectus, listing separately each exercised subscription right as to each beneficial owner (without identifying any such beneficial owner) for whom the Nominee Holder is acting hereby:

 

 
NUMBER OF
SHARES OWNED
ON RECORD DATE
NUMBER OF SHARES
SUBSCRIBED FOR
PURSUANT TO
SUBSCRIPTION RIGHT
 
     
     
     
     
     

 

 

 

____________________________________________
Name of Broker, Custodian Bank or Other Nominee
   

 

By:   ____________________________________
Authorized Signature
     
     
Name:   ____________________________________
    (please type or print)
 

Provide the following information if applicable:

 

 

 

________________________________________________

Depository Trust Company (“DTC”) Participant Number

 

 

________________________________________________

Participant

 

 

By:   _________________________
     
Name:   _________________________
     
Title   _________________________