EX-10.11



 EXHIBIT 10.11 
 INFINERA CORPORATION 
 AMENDED AND RESTATED CHANGE OF CONTROL SEVERANCE
AGREEMENT 
 This Amended and Restated Change of Control Severance Agreement (the “Agreement”) is made and entered
into by and between [NAME] (“Executive”) and Infinera Corporation (the “Company”), effective as of December 19, 2012 (the “Effective Date”). 
 RECITALS 
 1. It is expected that the Company from time to time will
consider the possibility of an acquisition by another company or other change of control. The Board of Directors of the Company (the “Board”) recognizes that such consideration can be a distraction to Executive and can cause Executive to
consider alternative employment opportunities. The Board has determined that it is in the best interests of the Company and its stockholders to assure that the Company will have the continued dedication and objectivity of Executive, notwithstanding
the possibility, threat or occurrence of a Change of Control (as defined herein) of the Company. 
 2. The Board believes that
it is in the best interests of the Company and its stockholders to provide Executive with an incentive to continue his or her employment and to motivate Executive to maximize the value of the Company upon a Change of Control for the benefit of its
stockholders. 
 3. The Board believes that it is imperative to provide Executive with certain benefits upon Executive’s
termination of employment following a Change of Control. These benefits will provide Executive with enhanced financial security and incentive and encouragement to remain with the Company notwithstanding the possibility of a Change of Control.

 4. This Agreement amends and restates the Change of Control Severance Agreement dated [DATES] between the Company and
Executive. 
 5. Certain capitalized terms used in the Agreement are defined in Section 6 below. 

AGREEMENT 
 NOW, THEREFORE, in consideration of the mutual covenants contained herein, the parties hereto agree as follows: 
 1. Term of Agreement. This Agreement will terminate upon the date that all of the obligations of the parties hereto with respect to this Agreement have been satisfied. 







 2. At-Will Employment. The Company and Executive acknowledge that Executive’s
employment is and will continue to be at-will, as defined under applicable law, except as may otherwise be specifically provided under the terms of any written formal employment agreement between the Company and Executive (an “Employment
Agreement”). If Executive’s employment terminates for any reason, including (without limitation) any termination prior to a Change of Control, Executive will not be entitled to any payments, benefits, damages, awards or compensation other
than as provided by this Agreement or under his or her Employment Agreement. 
 3. Severance Benefits. 

(a) Involuntary Termination Following a Change of Control. If within twelve (12) months following a Change of Control,
(A) the Company (or any parent or subsidiary of the Company) terminates Executive’s employment without Cause, or (B) Executive resigns his or her employment as a result of a Constructive Termination, then, subject to Section 4,
Executive will receive the following severance from the Company: 
 (i) Severance Payment. Executive will receive a lump
sum severance payment (less applicable withholding taxes) equal to one and one-half (1.5) times the Executive’s annual base salary (as in effect immediately prior to (A) the Change of Control, or (B) Executive’s termination,
whichever is greater). 
 (ii) Equity Awards. One hundred percent (100%) all equity awards granted to Executive
that are outstanding as of the date of Executive’s termination (the “Equity Awards”) will immediately vest and, if applicable, become exercisable. The Equity Awards will, to the extent applicable, remain exercisable following
Executive’s termination for the period prescribed in the related award agreements. 
 (iii) Continued Employee
Benefits. If Executive elects continuation coverage pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (“COBRA”) for Executive and Executive’s eligible dependents, within the time period prescribed
pursuant to COBRA, the Company will reimburse Executive for the COBRA premiums for such coverage (at the coverage levels in effect immediately prior to Executive’s termination) until the earlier of (A) a period of eighteen (18) months
from the last date of employment of Executive with the Company, or (B) the date upon which Executive and/or Executive’s eligible dependents becomes covered under similar plans. COBRA reimbursements will be made by the Company to Executive
consistent with the Company’s normal expense reimbursement policy. Notwithstanding the previous sentence, if the Company determines in its sole discretion that it cannot provide the foregoing benefit without potentially violating, or being
subject to an excise tax under, applicable law (including, without limitation, Section 2716 of the Public Health Service Act), the Company shall in lieu thereof provide to Executive a taxable monthly payment, payable on the last day of a given
month, in an amount equal to the monthly COBRA premium that Executive would be required to pay to continue Executive’s group health coverage in effect on the termination of employment date (which amount shall be based on the premium for the
first month of COBRA coverage), which payments shall be made regardless of whether Executive elects COBRA continuation coverage and shall commence on the month following Executive’s termination of employment and shall end on the earlier of
(x) the date upon which Executive obtains other employment, or (y) the date the Company has paid an amount equal to eighteen (18) payments. For the avoidance of doubt, the taxable payments in lieu of COBRA reimbursements may be used
for any purpose, including, but not limited to continuation coverage under COBRA, and shall be subject to all applicable tax withholdings. 

  
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 (b) Timing of Severance Payments. Subject to Section 3(f), the Company will pay
the severance payment to which Executive is entitled pursuant to Section 3(a)(i) as a lump sum no later than March 15 of the calendar year following the year in which Executive’s employment terminates. If Executive should die before
the severance amount has been paid, such unpaid amount will be paid to Executive’s designated beneficiary, if living, or otherwise to the personal representative of Executive’s estate. 

(c) Voluntary Resignation; Termination For Cause. If Executive’s employment with the Company terminates (i) voluntarily
by Executive (other than as a result of a Constructive Termination) or (ii) for Cause by the Company (or any parent or subsidiary of the Company), then Executive will not be entitled to receive severance or other benefits except for those (if
any) as may then be established under the Company’s then existing severance and benefits plans and practices or pursuant to other written agreements with the Company, including, without limitation, any Employment Agreement. 

(d) Disability; Death. If the Company terminates Executive’s employment as a result of Executive’s Disability, or
Executive’s employment terminates due to his or her death, then Executive will not be entitled to receive severance or other benefits except for those (if any) as may then be established under the Company’s then existing written severance
and benefits plans and practices or pursuant to other written agreements with the Company, including, without limitation, any Employment Agreement. 
 (e) Exclusive Remedy. In the event of a termination of Executive’s employment with the Company (or any parent or subsidiary of the Company), the provisions of this Section 3 are intended
to be and are exclusive and in lieu of any other rights or remedies to which Executive or the Company may otherwise be entitled, whether at law, tort or contract, in equity, or under this Agreement. Executive will be entitled to no benefits,
compensation or other payments or rights upon termination of employment other than those benefits expressly set forth in this Section 3. 
 4. Release Requirement; Section 409A. 
 (a) Release of Claims
Agreement. The receipt of any severance payments or benefits pursuant to this Agreement is subject to Executive signing and not revoking a separation agreement and release of claims in a form acceptable to the Company (the “Release”),
which must become effective and irrevocable no later than the sixtieth (60th) day following Executive’s termination of employment (the “Release Deadline”). If the Release does not become effective and irrevocable by the Release
Deadline, Executive will forfeit any right to severance payments or benefits under this Agreement. In no event will severance payments or benefits be paid or provided until the Release actually becomes effective and irrevocable. 

  
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 (b) Separation from Service. Notwithstanding anything to the contrary in this
Agreement, no Deferred Compensation Separation Benefits (as defined in clause (d)) will be paid or otherwise provided until Executive has a “separation from service” within the meaning of Section 409A. Similarly, no severance payable
to Executive, if any, pursuant to this Agreement that otherwise would be exempt from Section 409A pursuant to Treasury Regulation Section 1.409A-1(b)(9) will be payable until Executive has a “separation from service” within
the meaning of Section 409A. 
 (c) Timing of Payments. It is intended that none of the severance payments under
this Agreement will constitute Deferred Compensation Separation Benefits, but rather will be exempt from Section 409A as a payment that would fall within the “short-term deferral period” as described in clause (e) or resulting
from an involuntary separation from service as described in clause (f). However, any severance payments or benefits under this Agreement that would be considered Deferred Compensation Separation Benefits will be paid on, or, in the case of
installments, will not commence until, the sixtieth (60th) day following Executive’s separation from service, or, if later, such time as required by Section 4(d). Except as required by Section 4(d), any installment payments that
would have been made to Executive during the sixty (60) day period immediately following Executive’s separation from service but for the preceding sentence will be paid to Executive on the sixtieth (60th) day following
Executive’s separation from service and the remaining payments shall be made as provided in this Agreement. 
 (d)
Specified Employee. Notwithstanding anything to the contrary in this Agreement, if Executive is a “specified employee” within the meaning of Section 409A at the time of Executive’s termination (other than due to death),
then the severance payable to Executive, if any, pursuant to this Agreement, when considered together with any other severance payments or separation benefits that are considered deferred compensation under Section 409A (together, the
“Deferred Compensation Separation Benefits”) that are payable within the first six (6) months following Executive’s termination of employment, will become payable on the first payroll date that occurs on or after the date six
(6) months and one (1) day following the date of Executive’s termination of employment. All subsequent Deferred Compensation Separation Benefits, if any, will be payable in accordance with the payment schedule applicable to each
payment or benefit. Notwithstanding anything herein to the contrary, if Executive dies following his or her termination but prior to the six (6) month anniversary of his or her termination, then any payments delayed in accordance with this
paragraph will be payable in a lump sum as soon as administratively practicable after the date of Executive’s death and all other Deferred Compensation Separation Benefits will be payable in accordance with the payment schedule applicable to
each payment or benefit. Each payment and benefit payable under this Agreement is intended to constitute separate payments for purposes of Section 1.409A-2(b)(2) of the Treasury Regulations. 

(e) Short-Term Deferral. Any amount paid under this Agreement that satisfies the requirements of the “short-term
deferral” rule set forth in Section 1.409A-1(b)(4) of the Treasury Regulations shall not constitute Deferred Compensation Separation Benefits for purposes of clause (i) above. 

(f) Involuntary Separation. Amount paid under this Agreement that qualifies as a payment made as a result of an involuntary
separation from service pursuant to Section 1.409A-1(b)(9)(iii) of the Treasury Regulations that do not exceed the Section 409A Limit shall not constitute Deferred Compensation Separation Benefits for purposes of clause (i) above.


  
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 (g) Compliance with Section 409A. The foregoing provisions are intended to
comply with the requirements of Section 409A so that none of the severance payments and benefits to be provided hereunder will be subject to the additional tax imposed under Section 409A, and any ambiguities herein will be interpreted to
so comply. The Company and Executive agree to work together in good faith to consider amendments to this Agreement and to take such reasonable actions which are necessary, appropriate or desirable to avoid imposition of any additional tax or income
recognition prior to actual payment to Executive under Section 409A. 
 5. Limitation on Payments. In the event that
the severance and other benefits provided for in this Agreement or otherwise payable to Executive (i) constitute “parachute payments” within the meaning of Section 280G of the Code and (ii) but for this Section 5, would
be subject to the excise tax imposed by Section 4999 of the Code, then Executive’s severance benefits under Section 3(a) will be either: 
 (a) delivered in full, or 
 (b) delivered as to such lesser extent which would
result in no portion of such severance benefits being subject to excise tax under Section 4999 of the Code, whichever of the foregoing amounts, taking into account the applicable federal, state and local income taxes and the excise tax imposed
by Section 4999, results in the receipt by Executive on an after-tax basis, of the greatest amount of severance benefits, notwithstanding that all or some portion of such severance benefits may be taxable under Section 4999 of the Code. If
a reduction in severance and other benefits constituting “parachute payments” is necessary so that benefits are delivered to a lesser extent, reduction will occur in the following order: (i) reduction of cash payments;
(ii) cancellation of awards granted “contingent on a change in ownership or control” (within the meaning of Code Section 280G), (iii) cancellation of accelerated vesting of equity awards; (iv) reduction of employee
benefits. In the event that acceleration of vesting of equity award compensation is to be reduced, such acceleration of vesting will be cancelled in the reverse order of the date of grant of Executive’s equity awards. If two or more equity
awards are granted on the same date, each award will be reduced on a pro-rata basis. In no event shall the Executive have any discretion with respect to the ordering of payment reductions. 

Unless the Company and Executive otherwise agree in writing, any determination required under this Section 5 will be made in writing
by the Company’s independent public accountants immediately prior to Change of Control (the “Accountants”), whose determination will be conclusive and binding upon Executive and the Company for all purposes. For purposes of making the
calculations required by this Section 5, the Accountants may make reasonable assumptions and approximations concerning applicable taxes and may rely on reasonable, good faith interpretations concerning the application of Sections 280G and 4999
of the Code. The Company and Executive will furnish to the Accountants such information and documents as the Accountants may reasonably request in order to make a determination under this Section 5. The Company will bear all costs the
Accountants may reasonably incur in connection with any calculations contemplated by this Section 5. 

  
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 6. Definition of Terms. The following terms referred to in this Agreement will have
the following meanings: 
 (a) Cause. “Cause” will mean: (i) Executive’s willful failure to
substantially perform his or her duties and responsibilities to the Company or deliberate violation of a Company policy; (ii) Executive’s commission of any act of fraud, embezzlement, dishonesty or any other willful misconduct that has
caused or is reasonably expected to result in material injury to the Company; (iii) unauthorized use or disclosure by Executive of any proprietary information or trade secrets of the Company or any other party to whom Executive owes an
obligation of nondisclosure as a result of his or her relationship with the Company; or (iv) Executive’s willful breach of any of his or her obligations under any written agreement or covenant with the Company. The determination as to
whether Executive is being terminated for Cause will be made in good faith by the Company and will be final and binding on Executive. 
 (b) Change of Control. “Change of Control” of the Company will mean: 
 (i) any “person” (as such term is used in Sections 13(d) and 14(d) of the Securities Exchange Act of 1934, as amended) becomes the “beneficial owner” (as defined in Rule 13d-3 under
said Act), directly or indirectly, of securities of the Company representing fifty percent (50%) or more of the total voting power represented by the Company’s then outstanding voting securities; 

(ii) the consummation of the sale or disposition by the Company of all or substantially all of the Company’s assets; 

(iii) the consummation of a merger or consolidation of the Company with any other corporation, other than a merger or consolidation
which would result in the voting securities of the Company outstanding immediately prior thereto continuing to represent (either by remaining outstanding or by being converted into voting securities of the surviving entity or its parent) at least
fifty percent (50%) of the total voting power represented by the voting securities of the Company or such surviving entity or its parent outstanding immediately after such merger or consolidation; or 

(iv) a change in the composition of the Board occurring within a two (2) year period, as a result of which less than a majority of
the directors are Incumbent Directors. “Incumbent Directors” means directors who either (A) are directors of the Company as of the date hereof, or (B) are elected, or nominated for election, to the Board with the affirmative
votes of at least a majority of the directors of the Company at the time of such election or nomination (but will not include an individual whose election or nomination is in connection with an actual or threatened proxy contest relating to the
election of directors to the Company). 
 Notwithstanding the foregoing, a transaction will not be deemed a Change of Control
unless the transaction qualifies as a change in control event within the meaning of Section 409A, as it has been and may be amended from time to time, and any proposed or final Treasury Regulations and Internal Revenue Service guidance that has
been promulgated or may be promulgated thereunder from time to time. 

  
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 (c) Code. “Code” will mean the Internal Revenue Code of 1986, as amended.
Any reference to a section of the Code herein will be a reference to any successor or amended section of the Code. 
 (d)
Constructive Termination. “Constructive Termination” will mean Executive’s resignation as a result of, and within three (3) months following the expiration of any Company cure period (discussed below) following the
occurrence of one or more of the following: (i) a material reduction in Executive’s job, duties or responsibilities in a manner that is substantially inconsistent with the position, duties or responsibilities held by Executive immediately
before such reduction, (ii) a material reduction in Executive’s base salary (in other words, a reduction of more than five percent of Executive’s base salary within the twelve-month period following a Change of Control), or
(iii) a material change in the work location at which Executive is required to perform services for the Company (in other words, a requirement that Executive relocate to a work location that is more than 50 miles from Executive’s work
location in effect as of the date immediately prior to a Change in Control). Executive will not resign as the result of a Constructive Termination without first providing the Company with written notice of the acts or omissions constituting the
grounds for “Constructive Termination” within ninety (90) days of the initial existence of the grounds for “Constructive Termination” and a cure period of thirty (30) days following the date of such notice. 

(e) Disability. “Disability” will mean that Executive has been unable to perform his or her Company duties as the result
of his or her incapacity due to physical or mental illness, and such inability, at least twenty-six (26) weeks after its commencement, is determined to be total and permanent by a physician selected by the Company or its insurers and acceptable
to Executive or Executive’s legal representative (such Agreement as to acceptability not to be unreasonably withheld). Termination resulting from Disability may only be effected after at least thirty (30) days’ written notice by the
Company of its intention to terminate Executive’s employment. In the event that Executive resumes the performance of substantially all of his or her duties hereunder before the termination of his or her employment becomes effective, the notice
of intent to terminate will automatically be deemed to have been revoked. 
 (f) Section 409A. “Section
409A” will mean Section 409A of the Code and the final Treasury Regulations and any official Internal Revenue Service guidance promulgated thereunder. 
 (g) Section 409A Limit. “Section 409A Limit” will mean the lesser of two (2) times: (i) Executive’s annualized compensation based upon the annual rate of pay paid to
Executive during the Company’s taxable year preceding the Company’s taxable year of Executive’s termination of employment as determined under Treasury Regulation 1.409A-1(b)(9)(iii)(A)(1) and any Internal Revenue Service guidance
issued with respect thereto; or (ii) the maximum amount that may be taken into account under a qualified plan pursuant to Section 401(a)(17) of the Code for the year in which Executive’s employment is terminated. 

  
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 7. Successors. 

(a) The Company’s Successors. Any successor to the Company (whether direct or indirect and whether by purchase, merger,
consolidation, liquidation or otherwise) to all or substantially all of the Company’s business and/or assets will assume the obligations under this Agreement and will agree expressly to perform the obligations under this Agreement in the same
manner and to the same extent as the Company would be required to perform such obligations in the absence of a succession. For all purposes under this Agreement, the term “Company” will include any successor to the Company’s business
and/or assets which executes and delivers the assumption agreement described in this Section 6(a) or which becomes bound by the terms of this Agreement by operation of law. 

(b) Executive’s Successors. The terms of this Agreement and all rights of Executive hereunder will inure to the benefit of,
and be enforceable by, Executive’s personal or legal representatives, executors, administrators, successors, heirs, distributees, devisees and legatees. 
 8. Notice. 
 (a) General. Notices and all other communications
contemplated by this Agreement will be in writing and will be deemed to have been duly given when personally delivered or when mailed by U.S. registered or certified mail, return receipt requested and postage prepaid. In the case of Executive,
mailed notices will be addressed to him or her at the home address which he or she most recently communicated to the Company in writing. In the case of the Company, mailed notices will be addressed to its corporate headquarters, and all notices will
be directed to the attention of its President. 
 (b) Notice of Termination. Any termination by the Company for Cause or
as a result of a voluntary resignation will be communicated by a notice of termination to the other party hereto given in accordance with Section 7(a) of this Agreement. Such notice will indicate the specific termination provision in this
Agreement relied upon, will set forth in reasonable detail the facts and circumstances claimed to provide a basis for termination under the provision so indicated, and will specify the termination date (which will be not more than thirty
(30) days after the giving of such notice). Without limiting the foregoing, Executive shall be required to provide thirty (30) days’ notice prior to the termination of his employment for any reason. 

9. Arbitration. 
 (a) Any dispute or controversy arising out of, relating to, or in connection with this Agreement, or the interpretation, validity, construction, performance, breach, or termination thereof, will be
settled by binding arbitration to be conducted by the Judicial Arbitration and Mediation Services (“JAMS”) in Santa Clara, California, in accordance with the Employment Arbitration Rules and Procedures of JAMS (the “Rules”). The
arbitrator may grant injunctions or other relief in such dispute or controversy. The decision of the arbitrator will be final, conclusive and binding on the parties to the arbitration. Judgment may be entered on the arbitrator’s decision in any
court having jurisdiction. 
 (b) The arbitrator(s) will apply California law to the merits of any dispute or claim, without
reference to conflicts of law rules. The arbitration proceedings will be governed by federal arbitration law and by the Rules, without reference to state arbitration law. Executive hereby consents to the personal jurisdiction of the state and
federal courts located in California for any action or proceeding arising from or relating to this Agreement or relating to any arbitration in which the parties are participants. 

  
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 (c) Executive understands that nothing in this Section 8 modifies Executive’s
at-will employment status. Either Executive or the Company can terminate the employment relationship at any time, with or without Cause. 
 (d) EXECUTIVE HAS READ AND UNDERSTANDS THIS SECTION 8, WHICH DISCUSSES ARBITRATION. EXECUTIVE UNDERSTANDS THAT SUBMITTING ANY CLAIMS ARISING OUT OF, RELATING TO, OR IN CONNECTION WITH THIS AGREEMENT, OR
THE INTERPRETATION, VALIDITY, CONSTRUCTION, PERFORMANCE, BREACH OR TERMINATION THEREOF TO BINDING ARBITRATION, CONSTITUTES A WAIVER OF EXECUTIVE’S RIGHT TO A JURY TRIAL AND RELATES TO THE RESOLUTION OF ALL DISPUTES RELATING TO ALL ASPECTS OF
THE EMPLOYER/EXECUTIVE RELATIONSHIP, INCLUDING BUT NOT LIMITED TO, THE FOLLOWING CLAIMS: 
 (i) ANY AND ALL CLAIMS FOR WRONGFUL
DISCHARGE OF EMPLOYMENT; BREACH OF CONTRACT, BOTH EXPRESS AND IMPLIED; BREACH OF THE COVENANT OF GOOD FAITH AND FAIR DEALING, BOTH EXPRESS AND IMPLIED; NEGLIGENT OR INTENTIONAL INFLICTION OF EMOTIONAL DISTRESS; NEGLIGENT OR INTENTIONAL
MISREPRESENTATION; NEGLIGENT OR INTENTIONAL INTERFERENCE WITH CONTRACT OR PROSPECTIVE ECONOMIC ADVANTAGE; AND DEFAMATION. 

(ii) ANY AND ALL CLAIMS FOR VIOLATION OF ANY FEDERAL STATE OR MUNICIPAL STATUTE, INCLUDING, BUT NOT LIMITED TO, TITLE VII OF THE CIVIL
RIGHTS ACT OF 1964, THE CIVIL RIGHTS ACT OF 1991, THE AGE DISCRIMINATION IN EMPLOYMENT ACT OF 1967, THE AMERICANS WITH DISABILITIES ACT OF 1990, THE FAIR LABOR STANDARDS ACT, THE CALIFORNIA FAIR EMPLOYMENT AND HOUSING ACT, AND LABOR CODE SECTION
201, et seq; 
 (iii) ANY AND ALL CLAIMS ARISING OUT OF ANY OTHER LAWS AND REGULATIONS RELATING TO EMPLOYMENT OR EMPLOYMENT
DISCRIMINATION. 
 10. Miscellaneous Provisions. 

(a) No Duty to Mitigate. Executive will not be required to mitigate the amount of any payment contemplated by this Agreement, nor
will any such payment be reduced by any earnings that Executive may receive from any other source. 
 (b) Waiver. No
provision of this Agreement will be modified, waived or discharged unless the modification, waiver or discharge is agreed to in writing and signed by Executive and by an authorized officer of the Company (other than Executive). No waiver by either
party of any breach of, or of compliance with, any condition or provision of this Agreement by the other party will be considered a waiver of any other condition or provision or of the same condition or provision at another time. 

  
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 (c) Headings. All captions and section headings used in this Agreement are for
convenient reference only and do not form a part of this Agreement. 
 (d) Entire Agreement. This Agreement, together
with any Employment Agreement, constitutes the entire agreement of the parties hereto and supersedes in their entirety all prior representations, understandings, undertakings or agreements (whether oral or written and whether expressed or implied)
of the parties with respect to the subject matter hereof. 
 (e) Amendment. No waiver, alteration, or modification of any
of the provisions of this Agreement will be binding unless in writing and signed by duly authorized representatives of the parties hereto and which specifically mention this Agreement. 

(f) Choice of Law. The validity, interpretation, construction and performance of this Agreement will be governed by the laws of
the State of California (with the exception of its conflict of laws provisions). 
 (g) Severability. The invalidity or
unenforceability of any provision or provisions of this Agreement will not affect the validity or enforceability of any other provision hereof, which will remain in full force and effect. 

(h) Withholding. All payments made pursuant to this Agreement will be subject to withholding of applicable income, employment and
other taxes. 
 (i) Counterparts. This Agreement may be executed in counterparts, each of which will be deemed an
original, but all of which together will constitute one and the same instrument. 
 (Signature Page to Follow) 


  
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 IN WITNESS WHEREOF, each of the parties has executed this Agreement, in the case of the
Company by its duly authorized officer, as of the day and year set forth below. 
  

							
	COMPANY	 		 	INFINERA CORPORATION
				
		 		 	By:	 	 
				
		 		 	Name:	 	 
				
		 		 	Title:	 	 
				
	EXECUTIVE	 		 	By:	 	 
				
		 		 	Name:	 	 
				
		 		 	Title:	 	 


  
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