# **Exhibit 10.15**

 
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|----------------------------------|------------|
| ** **                       |
| ** **                       |
| ** **                       |
| ** **                       |
| **2005  RETENTION STOCK OPTION** |
| **AGREEMENT**                    |
| ** **                       |

 

# 1.     Grant of Option.  Intellisync Corporation, aDelaware corporation (the “Company”), hereby grants to [                ] (“Optionee”), an option (the “Option”) topurchase the total number of shares of Common Stock (the “Shares”) setforth in the notice of stock option grant, as attached hereto as Exhibit A(the “Notice”), which may be transmitted to or viewed online byOptionee, (the terms of which are incorporated herein by this reference), atthe exercise price per Share set forth in the Notice (the “Exercise Price”).  This Agreement shall be deemed executed bythe Company and Optionee upon Optionee’s online acceptance of the Option.

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# 2.     Designation of Option.  ThisOption is intended to be an Incentive Stock Option as defined in Section 422of the Code only to the extent so designated in the Notice, and to the extentit is not so designated or fails to qualify as an Incentive Stock Option, it isintended to be a Non-statutory Stock Option. 

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# Notwithstandingthe above, if designated as an Incentive Stock Option, in the event that theShares subject to this Option (and all other Incentive Stock Options granted toOptionee by the Company or any Parent or Subsidiary, including under otherplans of the Company) that first become exercisable in any calendar year havean aggregate fair market value (determined for each Share as of the date ofgrant of the option covering such Share) in excess of $100,000, the Shares inexcess of $100,000 shall be treated as subject to a Non-statutory Stock Option.

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# 3.     Terms, Conditions And Form Of Options.  TheOption shall be subject to the following terms and conditions: 

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## (a)   OptionExercise Price.  The option exerciseprice for each Option shall be established in the sole discretion of the Boardof Directors of the Company (the “Board”); *provided*, *however*, that (i) the option exercise price per sharefor an Incentive Stock Option shall be not less than the Fair Market Value, asdetermined by the Board, of a Share on the date of the granting of the Option, (ii) theoption exercise price per Share for a Non-statutory Stock Option shall not beless than eighty-five percent (85%) of the fair market value, as determined bythe Board, of a Share on the date of the granting of the Option and (iii) noIncentive Stock Option granted to an Optionee who at the time the Option isgranted owns stock possessing more than ten percent (10%) of the total combinedvoting power of all classes of stock of a Participating Company within themeaning of section 422(b)(6) of the Code (a “Ten Percent OwnerOptionee”) shall have an option exercise price per share less than onehundred ten percent (110%) of the fair market value, as determined by theBoard, of a Share on the date of the granting of the Option.  Notwithstanding the foregoing, an Option(whether an Incentive Stock Option or a Non-statutory Stock Option) may begranted with an option exercise price lower than the minimum exercise price setforth above if such Option is granted pursuant to an assumption or substitutionfor another option in a manner qualifying with the provisions of section 424(a) ofthe Code. 

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## (b)   ExercisedPeriod of Options.  The Board shall havethe power to set the time or times within which each Option shall beexercisable or the event or events upon the occurrence of which all or aportion of each Option shall be exercisable, including vesting requirementsand/or performance criteria with respect to the Company and/or the Optionee,and the term of each Option; *provided*, *however*, that (i) no Option shall be exercisable afterthe expiration of ten (10) years after the date such Option is granted,and (ii) no Incentive Stock Option granted to a Ten Percent Owner Optioneeshall be exercisable after the expiration of five (5) years after the datesuch Option is granted.  The Board shallhave the discretion to determine whether and to what extent the vesting ofOptions shall be tolled during any unpaid leave of absence; *provided*, *however*, thatin the absence of such determination, vesting of Options shall be tolled afterthe thirtieth (30th calendar day of any such unpaid leave (unlessotherwise required by the Applicable Laws). In the event of military leave, vesting shall toll during any unpaidportion of such leave, provided that, upon an Optionee’s returning frommilitary leave (under conditions that would entitle him or her to protectionupon such return under the Uniform Services Employment and Reemployment RightsAct), he or she shall be given vesting credit with respect to Options to thesame extent as would have applied had the Optionee continued to provideservices to the Company throughout the leave on the same terms as he or she wasproviding services immediately prior to such leave. 

 

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# 4.     Exercise of Option.  ThisOption shall be exercisable during its term in accordance with theVesting/Exercise Schedule set out in the Notice and as set forth below, *provided*, *however*, thatto the extent that any Shares subject to this Option are exercisable prior tovesting, such Shares shall be subject to a right of repurchase by the Company:

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## (a)   Rightto Exercise.

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### (i)    ThisOption may not be exercised for a fraction of a Share. 

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### (ii)   Inthe event of Optionee’s death, Disability or other termination of employment orservice relationship, the exercisability of the Option is governed by Section 6below, subject to the limitations contained in this Section 4.

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### (iii)  Inno event may this Option be exercised after the Expiration Date of the Optionas set forth in the Notice.

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## (b)   Methodof Exercise.

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### (i)    ThisOption shall be exercisable by delivering to the Company a written notice ofexercise (in the form attached as Exhibit B or in any other form ofnotice approved by the Board) which shall state Optionee’s election to exercisethe Option, the number of Shares with respect to which the Option is beingexercised, and such other representations and agreements as to the holder’sinvestment intent with respect to such Shares as may be required by the Companyand the Applicable Laws.  Such writtennotice shall be signed by Optionee and shall be delivered to the Company (orits designee) by such means as are determined by the Board in its discretion toconstitute adequate delivery.  Toexercise the Option, Optionee must either accompany the written notice withpayment of the aggregate exercise price for the Shares being exercised orprovide satisfactory assurance to the Company that delivery of such exerciseprice will be made promptly and in a manner that complies with the ApplicableLaws.  With respect to an exercisepursuant to Section 5(a) or (b) below, the Option shall bedeemed to be exercised upon receipt by the Company of the written exercisenotice accompanied by the exercise price. With respect to an exercise pursuant to Section 5(c) below,the Option shall be deemed to be exercised upon receipt by the Company of theirrevocable broker instructions.

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### (ii)   TheCompany is not obligated, and will have no liability for failure, to issue ordeliver any Shares upon exercise of the Option unless such issuance or deliverywould comply with the Applicable Laws, with such compliance determined by theCompany in consultation with its legal counsel.  This Option may not be exercised if theissuance of such Shares upon such exercise or the method of payment ofconsideration for such Shares would constitute a violation of any ApplicableLaw, including without limitation any rule under Part 221 ofTitle 12 of the Code of Federal Regulations as promulgated by the FederalReserve Board.  As a condition to theexercise of this Option, the Company may require Optionee to make anyrepresentation and warranty to the Company as may be required by the ApplicableLaws.  Assuming such compliance, forincome tax purposes the Shares shall be considered transferred to Optionee onthe date on which the Option is exercised with respect to such Shares.

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### (iii)  Asa condition to the exercise of this Option, Optionee agrees to make adequateprovision for federal, state or other tax withholding obligations, if any,which arise upon the vesting or exercise of the Option, or disposition ofShares, whether by withholding Shares subject to the Option, direct payment tothe Company, or otherwise.

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# 5.     Method of Payment.  Paymentof the Exercise Price shall be by any of the following, or a combination of thefollowing, at the election of Optionee:  

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## (a)   cash,check or other cash equivalent; 

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## (b)   surrenderto the Company of other shares of Common Stock of the Company that have anaggregate Fair Market Value on the date of surrender equal to the ExercisePrice of the Shares as to which the Option is being exercised.  In the case of shares acquired directly orindirectly from the Company, such shares must have been owned by Optionee formore than six (6) months on the date of surrender (or such otherperiod of time as is necessary to avoid the Company’s incurring adverseaccounting charges); or

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## (c)   ifthe Company is then permitting options to be exercised through a “cashless”brokered exercise program, delivery of a properly executed exercise noticetogether with irrevocable instructions to a broker to deliver

 

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## to the Company promptly and in a manner that complieswith all Applicable Laws the funds necessary to satisfy the aggregate exerciseprice and any applicable tax withholding; provided that the Company reserves atall times the right in the Company’s sole and absolute discretion to decline toapprove or to terminate any such program or procedure. 

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# 6.     Termination of Relationship; Effect on Option.  Followingthe date of termination (the “Termination Date”) of Optionee’scontinuous employment, consulting or other service relationship with theParticipating Company Group (a “Termination”) for any reason, Optioneemay exercise the Option only as set forth in the Notice and this Section 6.  To the extent that Optionee is not vested inthe Shares as of the Termination Date, or if Optionee does not exercise thisOption with respect to vested Shares within the Termination Period set forth inthe Notice or the termination periods set forth below, the Option shallterminate in its entirety.  In no event,may any Option be exercised after the Expiration Date of the Option as setforth in**the Notice.

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# Optionee’s continuous servicewith the Participating Company Group shall not be deemed to terminate ifOptionee takes any military leave, sick leave, or other bona fide leave ofabsence approved by the Company of ninety (90) days or less.  In the event of a leave of absence in excessof ninety (90) days, Optionee’s continuous service shall be deemed to terminateon the ninety-first (91st) day of such leave unless his or her rightto return to service with the Participating Company Group remains guaranteed bycontract or statute.  A change in statusfrom one form of service-provider to another (e.g., from employee toconsultant) shall not constitute a Termination.

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## (a)   TerminationNot as a Result of Disability or Death. In the event of Termination for any reason other than as a result ofOptionee’s Disability or death, Optionee may, to the extent vested in theShares as of the Termination Date, exercise this Option as to such vestedShares only during the ninety (90) day period beginning on the TerminationDate.

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## (b)   OtherTerminations.  In connection with anyTermination other than a Termination covered by Section 6(a), Optionee mayexercise the Option only as described below:

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## (c)   Terminationupon Disability of Optionee.  In theevent of Termination as a result of Optionee’s Disability, Optionee may, to theextent vested in the Shares as of the Termination Date, exercise this Optionwithin twelve (12) months from the Termination Date.  

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### (i)    Deathof Optionee.  In**theevent of the death of Optionee (a) during the term of this Option andwhile an employee, consultant or other service provider of the Company andhaving been in continuous service status since the date of grant of the Option,or (b) within three (3) months after Optionee’s Termination Date, theOption may be exercised at any time within twelve (12) months following thedate of death by Optionee’s estate or by a person who acquired the right toexercise the Option by bequest or inheritance, but only to the extent Optioneewas vested in the Shares as of the Termination Date.

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## (d)   Extensionof Exercise Prevented by Law. Notwithstanding the foregoing, if the exercise of the Option within theapplicable time periods set forth above is prevented by the provisions of Section 3(b)(ii) above,the Option shall remain exercisable for a period of up to three (3) monthsafter the date that the circumstances preventing such exercise lapse; *provided*that the Option shall not be exercisable after theExpiration Date of the Option as set forth in the Notice.  The Company makes no representation as to thetax consequences of any such delayed exercise period.  The Optionee should consult with his or herown tax advisor as to the tax consequences of any such delayed exercise period.     

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# 7.     Non-Transferability of Option.  Except asotherwise set forth in the Notice, this Option may not be transferred in anymanner otherwise than by will or by the laws of descent or distribution and maybe exercised during the lifetime of Optionee only by him or her.  The terms of this Option shall be bindingupon the executors, administrators, heirs, successors and assigns of Optionee.

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# 8.     Rights as Stockholder.  Until theissuance of the Shares following exercise of an Option (as evidenced by theappropriate entry on the books of the Company or of a duly authorized transferagent of the Company), no right to vote or receive dividends or any otherrights as a stockholder shall exist with respect to the Shares subject to anOption. 

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# 9.     No Employment Rights.  ThisAgreement shall not confer upon any Optionee any right with respect tocontinuation of an employment or consulting relationship with the Company, norshall it interfere in any way

 

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# with such participant’s right orthe Company’s right to terminate the employment or consulting relationship atany time for any reason. 

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# 10.   Notice of Disqualifying Dispositions.  Withrespect to any Shares issued upon exercise of an Incentive Stock Option, ifOptionee sells or otherwise disposes of such Shares on or before the later of (i) thedate two (2) years after the Option grant date, or (ii) the date one (1) yearafter the date of exercise, Optionee shall immediately notify the Company inwriting of such disposition.  Optioneeacknowledges and agrees that he or she may be subject to income tax withholdingby the Company on the compensation income recognized by Optionee from the earlydisposition by payment in cash or out of the current earnings paid to Optionee.

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# 11.   Changes in Capital Stock; Corporate Transactions.  Subjectto any action required under the Applicable Laws by the stockholders of theCompany, the number of Shares covered under this Agreement, as well as theexercise price per share of outstanding Options, shall be proportionatelyadjusted for any increase or decrease in the number of issued Shares resultingfrom a stock split, reverse stock split, stock dividend, combination,recapitalization or reclassification of the Common Stock, or any other increaseor decrease in the number of issued Shares effected without receipt ofconsideration by the Company; *provided*, *however*, that conversion of any convertible securities ofthe Company shall not be deemed to have been “effected without receipt ofconsideration.”  Such adjustment shall bemade by the Board, whose determination in that respect shall be final, bindingand conclusive.  Except as expresslyprovided herein, no issuance by the Company of shares of stock of any class, orsecurities convertible into shares of stock of any class, shall affect, and noadjustment by reason thereof shall be made with respect to, the number or priceof Shares subject to an Option.

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# 12.   Transfer of Control; Liquidation.  A “Transfer of Control” shall bedeemed to have occurred in the event of (a) a sale of all or substantiallyall of the Company’s assets, (b) a merger, consolidation or other capitalreorganization or transaction of the Company with or into another corporation,entity or person. 

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In the event of a Transfer of Control, the Board, inits sole discretion, may arrange with the surviving, continuing, successor, orpurchasing corporation or parent corporation thereof, as the case may be (the “Acquiring Corporation”), for theAcquiring Corporation to either assume the Options hereunder or substituteoptions for the Acquiring Corporation’s stock for this Option.  Any Options which are neither assumed,substituted for by the Acquiring Corporation in connection with the Transfer ofControl, nor exercised as of the date of the Transfer of Control, shallterminate and cease to be outstanding effective as of the date of the Transferof Control. 

 

In the event of a liquidation or dissolution of theCompany, this Option will terminate immediately prior to the consummation ofsuch action, unless otherwise determined by the Board in its sole discretion. 

 

# 13.   Definitions.  As used herein, the followingdefinitions shall apply:

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## (a)   “Agreement”means this 2005 Retention Stock Option Agreement between the Company andOptionee evidencing the terms and conditions of this Option.

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## (b)   “ApplicableLaws” means the requirements relating to the administration of stockoptions under U.S. state corporate laws, U.S. federal and state securitieslaws, the Code, any stock exchange or quotation system on which the CommonStock is listed or quoted and the applicable laws of any foreign country orjurisdiction that may apply to this Option.

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## (c)   “Code”means the Internal Revenue Code of 1986, as amended.

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## (d)   “CommonStock” means the common stock of the Company.

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## (e)   “Disability”means total and permanent disability as defined in Section 22(e)(3) ofthe Code.

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## (f)    “FairMarket Value” means, as of any date, the value of Common Stock determinedas follows:

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### (i)    Ifthe Common Stock is listed on any established stock exchange or a nationalmarket system, including without limitation the Nasdaq National Market or TheNasdaq SmallCap Market of The Nasdaq Stock Market, its Fair Market Value shallbe the closing sales price for such stock (or the closing bid, if no sales werereported) as quoted on such exchange or system on the day of determination, asreported in *The Wall Street Journal* or such othersource as the Administrator deems reliable;

 

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### (ii)   Ifthe Common Stock is regularly quoted by a recognized securities dealer butselling prices are not reported, its Fair Market Value shall be the meanbetween the high bid and low asked prices for the Common Stock on the day ofdetermination; or

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### (iii)  Inthe absence of an established market for the Common Stock, the Fair MarketValue thereof shall be determined in good faith by the Board.

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## (g)   “Non-statutoryStock Option” means an Option not intended to qualify as an incentive stockoption within the meaning of Section 422 of the Code and the regulationspromulgated thereunder.

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## (h)   “Parent”means a “parent corporation,” whether now or hereafter existing, as defined in Section 424(e) ofthe Code.

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## (i)    “Subsidiary”means a “subsidiary corporation”, whether now or hereafter existing, as definedin Section 424(f) of the Code.

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# 14.   Miscellaneous Provisions.

 

## (a)   Effectof Agreement.  This Agreement shallbe administered by the Board and/or by one or more duly appointed committees(collectively, the “Committee”)of the Board having such powers as shall be specified by the Board.  The composition of, and authority delegatedto, the Committee shall conform to any mandatory requirements of the ApplicableLaws.  Subsequent references herein tothe Board shall also mean the Committee if such Committee has been appointedand, unless the powers of the Committee have been specifically limited, theCommittee shall have all of the powers of the Board granted herein, including,without limitation, the power to terminate or amend this Agreement at any time,subject to any limitations imposed by the Applicable Laws.   

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## All questions of interpretation of this Agreement orof the Option granted hereunder shall be determined by the Board, and suchdeterminations shall be final and binding upon all persons having an interesthereunder. 

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## (b)   Choiceof Law; Arbitration.  This Agreementshall be governed by, and construed in accordance with, the laws of the Stateof California, as such laws are applied to contracts entered into and performedin such State.  Any dispute orcontroversy arising under or in connection with this Agreement shall be settledexclusively in arbitration conducted in Santa Clara County, California, inaccordance with the rules of the American Arbitration Association then ineffect.  Judgment may be entered on thearbitrator’s award in any court having jurisdiction.  Punitive damages shall not be awarded.  In any arbitration proceeding, the partydetermined to be the prevailing party shall be entitled to receive, in additionto any other award, its attorneys’ fees and expenses of the proceeding.

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# 15.   Data Protection Matters.  In orderto facilitate administration of the Option, it will be necessary for theCompany or the Subsidiary that employs Optionee (or its or their payrolladministrators) to collect, hold and process certain personal information aboutOptionee and to transfer this data to the Company and to certain third partiessuch as brokers with whom Optionee may elect to deposit shares, as well asother third party outsource service providers engaged in administering stockoption matters.  Optionee consents to theCompany or the applicable Subsidiary (or its or their agents or administrators)collecting, holding and processing such personal data and transferring suchdata to the Company or any other parties insofar as it is reasonably necessaryto implement, administer and manage the Option. Where such a transfer is to a destination outside the country in whichOptionee resides, or outside the European Economic Area, the Company (and itsagents and administrators) shall take reasonable steps to ensure that Optionee’spersonal data continues to be adequately protected and securely held.  Optionee understands that Optionee may, atany time, view his or her personal data, require any necessary corrections toit, or withdraw the consents contained herein in writing by contacting theHuman Resources Department of the Company (or if applicable the Human ResourcesDepartment of the Subsidiary that employs Optionee) (but Optionee acknowledgesthat without the use of such data it may not be practicable for the Company toadminister the Option in a timely fashion or at all and this may be detrimentalto Optionee).

 

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|-----------------------------|------------|
| ** **                  |
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| ** **                  |
| **EXHIBIT A**          |
| **NOTICE OF NON-STATUTORY** |
| **STOCK OPTION GRANT**      |
| ** **                  |

 
| «First_Name» «Last_Name»         |   |   | ** ** | Option No.:  **0000000000«Option_»** |
|------------------------------------------------------|--------|--------|------------|----------------------------------------------------------|
| «Address_Line_1»                           |   |   |       | 2005 Retention  Stock Option Agreement                   |
| «Address_Line_2»                           |   |   |       |                                                     |
| «City», «State»  «Zip» |   |   |       |                                                     |
| «Country»                                  |   |   |       |                                                     |

 

Youhave been granted an option to purchase Common Stock of Intellisync Corporation(the “Company”) as follows:

 
| Date of Option Grant:      | ** ** | **«Date_of_Grant»**   |
|----------------------------|------------|---------------------------------|
| Exercise Price Per Share:  |       | $**«Exercise_Price»** |
| Total Exercise Price:      |       | $**«Exercise_Price»** |
| Number of Option Shares:   | ** ** | **«M__of_Options»**   |
| Option Expiration Date:    | ** ** | **«Expiration_Date»** |
| Vesting Commencement Date: | ** ** | **«Vesting_Date»**    |

 

**Vesting/ExerciseSchedule:**  So long as your employment, consulting orother service relationship with the Company continues, the Shares underlyingthis Option shall vest and become exercisable in accordance with the followingschedule:

 

one-fourth of the total number of Shares subject tothe Option shall vest and become exercisable on the twelve month anniversary ofthe Vesting Commencement Date and 1/48th of the total number ofShares subject to the Option shall vest and become exercisable each monththereafter, so that the Option shall be fully vested and exercisable on thefourth anniversary of the Vesting Commencement Date (assuming you remain in acontinuous service relationship with the Company through that date).

 

**TerminationPeriod:**  The Option may be exercised as to vestedShares only for three (3) months after termination of employment orconsulting relationship except as set out in Section 6 of the Agreement(but in no event later than the Expiration Date).  You are responsible for keeping track ofthese exercise periods following termination for any reason of your employmentor other service relationship with the Company. The Company will not provide further notice of such periods.

 

**Transferability: **This Option may not be transferred.

 

**Acceptance**:  ThisGrant may only be accepted by following the procedure below.  Youmust accept the Grant before you can exercise the Option.  MAKE SURE YOU READ THE AGREEMENT CAREFULLYPRIOR TO YOUR ACCEPTANCE.  If youagree to the terms of the Agreement, follow the procedure below to officiallyaccept the Grant.

** **

•      Go to the WealthViewswebsite: https://www.wealthviews.com/sync 

•      Log In using your USER IDand PASSWORD

•      Click on “Grant History”under the STOCK OPTIONS menu on the left-hand side of the screen. 

•      Click on “Pending” for eachof your grants 

•      Click the “I ACCEPT” buttonon the bottom of each of your grant documents. 

 

Byyour electronic acceptance of this Option Grant, you and the Company agree thatthis option is granted under and governed by the terms and conditions of theAgreement.

 

In addition, you agreeand acknowledge that your rights to any Shares underlying the Option will beearned only as you provide services to the Company over time, that the grant ofthe Option is not as consideration for services you rendered to the Companyprior to your Vesting Commencement Date, and that nothing in this Notice or theAgreement documentation confers upon you any right to continue your employment,consulting or other service relationship with the Company for any period oftime, nor does it interfere in any way with your right or the right of theCompany to terminate that relationship at any time, for any reason, with orwithout cause.

 

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| ** **          |
| ** **          |
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| **EXHIBIT B**  |
| **EXERCISE NOTICE** |
| ** **          |
| ** **          |

 

Intellisync Corporation

2550 North First Street, Suite 500

San Jose, CA 95131

Attention:  Stock Administrator

 

1.     Exerciseof Option.  Effective as of today,                                 ,          , the undersigned (“Purchaser”)hereby elects to purchase                             shares (the “Shares”) of the Common Stock of Intellisync Corporation(the “Company”) under and pursuant to the 2005 Retention Stock OptionAgreement dated                             (the“Award Agreement”).  The purchaseprice for the Shares will be $                            ,as required by the Award Agreement.

 

2.     Deliveryof Payment.  Purchaser herewithdelivers to the Company the full purchase price for the Shares and any requiredwithholding taxes to be paid in connection with the exercise of the Option.

 

3.     Representationsof Purchaser.  Purchaser acknowledgesthat Purchaser has received, read and understood the Award Agreement and agreesto abide by and be bound by its terms and conditions.

 

4.     Rightsas Stockholder.  Until the issuance(as evidenced by the appropriate entry on the books of the Company or of a dulyauthorized transfer agent of the Company) of the Shares, no right to vote orreceive dividends or any other rights as a stockholder will exist with respectto the Shares subject to the Option, notwithstanding the exercise of theOption.  The Shares so acquired will beissued to Purchaser as soon as practicable after exercise of the Option.  No adjustment will be made for a dividend orother right for which the record date is prior to the date of issuance.

 

5.     TaxConsultation.  Purchaser understandsthat Purchaser may suffer adverse tax consequences as a result of Purchaser’spurchase or disposition of the Shares. Purchaser represents that Purchaser has consulted with any taxconsultants Purchaser deems advisable in connection with the purchase ordisposition of the Shares and that Purchaser is not relying on the Company forany tax advice.

 

6.     EntireAgreement; Governing Law.  The AwardAgreement is incorporated herein by reference. This Agreement and the Award Agreement constitute the entire agreementof the parties with respect to the subject matter hereof and supersede in theirentirety all prior undertakings and agreements of the Company and Purchaserwith respect to the subject matter hereof, and may not be modified adversely tothe Purchaser’s interest except by means of a writing signed by the Company andPurchaser.  This agreement is governed bythe internal substantive laws, but not the choice of law rules, of California.

 
| Submitted by:  |       | Accepted by:                |
|----------------|------------|-----------------------------|
|           |       |                        |
| **PURCHASER:** | ** ** | **INTELLISYNC CORPORATION** |
| ** **     | ** ** | ** **                  | ** ** |
| ** **     | ** ** | ** **                  | ** ** |
| Print Name:    |       |                        | Its: |   |   |
|           |       |                        |   |   |   |
| Address:       |       |                        | Address: |   |   |
|           |       |                        |   |   |   |
|           |       |                        |   |
|           |       |                        |   |   |   |
|           |       |                        | Date Received: |   |   |
|                |            |                             |  |  |  |  |  |  |  |

 

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