Document:

Form of Medium-Term Notes, Series K, Principal at Risk Securities

 Exhibit 4.1 

[Face of Note] 

Unless this certificate is presented by an authorized representative of The Depository Trust Company, a New York corporation
(“DTC”), to the Company or its agent for registration of transfer, exchange or payment, and any certificate issued is registered in the name of Cede & Co. or in such other name as requested by an authorized representative
of DTC (and any payment is made to Cede & Co. or such other entity as is requested by an authorized representative of DTC), ANY TRANSFER, PLEDGE OR OTHER USE HEREOF FOR VALUE OR OTHERWISE BY OR TO ANY PERSON IS WRONGFUL inasmuch as the
registered owner hereof, Cede & Co., has an interest herein. 
  

					
	 CUSIP NO. 94986RM57
	  	 	FACE AMOUNT: $                        	  
	 REGISTERED NO.       
	  			

 WELLS FARGO & COMPANY 

MEDIUM-TERM NOTE, SERIES K 

Due Nine Months or More From Date of Issue 

Principal at Risk Securities Linked to the Russell 2000® Index 

due July 11, 2019 

WELLS FARGO & COMPANY, a corporation duly organized and existing under the laws of the State of Delaware (hereinafter
called the “Company,” which term includes any successor corporation under the Indenture hereinafter referred to), for value received, hereby promises to pay to CEDE & Co., or registered assigns, an amount equal to the
Redemption Amount (as defined below), in such coin or currency of the United States of America as at the time of payment is legal tender for payment of public and private debts, on the Stated Maturity Date. The “Initial Stated Maturity
Date” shall be July 11, 2019. If the Calculation Day (as defined below) is not postponed, the Initial Stated Maturity Date will be the “Stated Maturity Date.” If the Calculation Day is postponed, the “Stated
Maturity Date” shall be the later of (i) the Initial Stated Maturity Date and (ii) the third Business Day (as defined below) after the Calculation Day as postponed. This Security shall not bear any interest. 

Any payments on this Security at Maturity will be made against presentation of this Security at the office or agency of the
Company maintained for that purpose in the City of Minneapolis, Minnesota and at any other office or agency maintained by the Company for such purpose. 

“Face Amount” shall mean, when used with respect to this Security, the amount set forth on the face of this
Security as its “Face Amount.” 

 Determination of Redemption Amount 

The “Redemption Amount” of this Security will equal: 

 

	 	•	 	 if the Ending Level is greater than the Starting Level: the lesser of: 

 

	 	(i)	 Face Amount plus: 

 

															
	 	 	Face Amount    x    	 	 	 	 Ending Level – Starting Level

Starting Level
	 	 	 	    x    Participation Rate	 	 	 	  ; and

  

	 	(ii)	 the Capped Value; 

  

	 	•	 	 if the Ending Level is less than or equal to the Starting Level, but greater than or equal to the Threshold
Level: the Face Amount; or 

  

	 	•	 	 if the Ending Level is less than the Threshold Level: 

 

									
	 	 	Face Amount    x        	 	 Ending Level

Starting Level
	 	        x    Multiplier	 	 

 All calculations with respect to the Redemption Amount will be rounded to the nearest one hundred-thousandth,
with five one-millionths rounded upward (e.g., 0.000005 would be rounded to 0.00001); and the Redemption Amount will be rounded to the nearest cent, with one-half cent rounded upward. 

“Index” shall mean the Russell 2000® Index. 

The “Pricing Date” shall mean May 3, 2016. 

The “Starting Level” is 1,121.756, the Closing Level of the Index on the Pricing Date. 

The “Closing Level” of the Index on any Trading Day means the official closing level of the Index reported by
the Index Sponsor on such Trading Day, as obtained by the Calculation Agent on such Trading Day from the licensed third-party market data vendor contracted by the Calculation Agent at such time; in particular, taking into account the decimal
precision and/or rounding convention employed by such licensed third-party market data vendor on such date, subject to the provisions set forth below under “Discontinuance of The Index; Alteration of Method of Calculation” and “Market
Disruption Events.” 
 The “Ending Level” will be the Closing Level of the Index on the Calculation
Day. 
 The “Threshold Level” is 729.1414, which is equal to 65% of the Starting Level. 

The “Participation Rate” is 200%. 

  
 2 

 The “Capped Value” is 128.90% of the Face Amount of this
Security. 
 The “Multiplier” is equal to the Starting Level divided by the Threshold Level. 

“Index Sponsor” shall mean Frank Russell Company, doing business as Russell Investment Group. 

“Business Day” shall mean a day, other than a Saturday or Sunday, that is neither a legal holiday nor a day
on which banking institutions are authorized or required by law or regulation to close in New York, New York. 
 A
“Trading Day” means a day, as determined by the Calculation Agent, on which (i) the Relevant Stock Exchanges with respect to each security underlying the Index are scheduled to be open for trading for their respective regular
trading sessions and (ii) each Related Futures or Options Exchange is scheduled to be open for trading for its regular trading session. 

The “Related Futures or Options Exchange” for the Index means an exchange or quotation system where trading
has a material effect (as determined by the Calculation Agent) on the overall market for futures or options contracts relating to the Index. 

The “Relevant Stock Exchange” for any security underlying the Index means the primary exchange or quotation
system on which such security is traded, as determined by the Calculation Agent. 
 The “Calculation Day”
shall be July 3, 2019. If such day is not a Trading Day, the Calculation Day will be postponed to the next succeeding Trading Day. The Calculation Day is also subject to postponement due to the occurrence of a Market Disruption Event (as
defined below). If a Market Disruption Event occurs or is continuing with respect to the Index on the Calculation Day, such Calculation Day will be postponed to the first succeeding Trading Day on which a Market Disruption Event has not occurred and
is not continuing; however, if such first succeeding Trading Day has not occurred as of the eighth Trading Day after the originally scheduled Calculation Day, that eighth Trading Day shall be deemed to be the Calculation Day. If the Calculation Day
has been postponed eight Trading Days after the originally scheduled Calculation Day and a Market Disruption Event occurs or is continuing on such eighth Trading Day, the Calculation Agent will determine the Closing Level of the Index on such eighth
Trading Day in accordance with the formula for and method of calculating the Closing Level of the Index last in effect prior to commencement of the Market Disruption Event, using the closing price (or, with respect to any relevant security, if a
Market Disruption Event has occurred with respect to such security, its good faith estimate of the value of such security at the Scheduled Closing Time of the Relevant Stock Exchange for such security or, if earlier, the actual closing time of the
regular trading session of such Relevant Stock Exchange) on such date of each security included in the Index. As used herein, “closing price” means, with respect to any security on any date, the Relevant Stock Exchange traded or
quoted price of such security as of the Scheduled Closing Time of the Relevant Stock Exchange for such security or, if earlier, the actual closing time of the regular trading session of such Relevant Stock Exchange. 

  
 3 

 “Calculation Agent Agreement” shall mean the Calculation Agent
Agreement dated as of March 18, 2015 between the Company and the Calculation Agent, as amended from time to time. 

“Calculation Agent” shall mean the Person that has entered into the Calculation Agent Agreement with the
Company providing for, among other things, the determination of the Ending Level and the Redemption Amount, which term shall, unless the context otherwise requires, include its successors under such Calculation Agent Agreement. The initial
Calculation Agent shall be Wells Fargo Securities, LLC. Pursuant to the Calculation Agent Agreement, the Company may appoint a different Calculation Agent from time to time after the initial issuance of this Security without the consent of the
Holder of this Security and without notifying the Holder of this Security. 
 Discontinuance Of The Index; Alteration Of Method Of Calculation

 If the Index Sponsor discontinues publication of the Index, and the Index Sponsor or another entity publishes a
successor or substitute equity index that the Calculation Agent determines, in its sole discretion, to be comparable to the Index (a “Successor Equity Index”), then, upon the Calculation Agent’s notification of that
determination to the Trustee and the Company, the Calculation Agent will substitute the Successor Equity Index as calculated by the Index Sponsor or any other entity and calculate the Ending Level as described above. Upon any selection by the
Calculation Agent of a Successor Equity Index, the Company will cause notice to be given to the Holder of this Security. 

In the event that the Index Sponsor discontinues publication of the Index prior to, and the discontinuance is continuing on,
the Calculation Day and the Calculation Agent determines that no Successor Equity Index is available at such time, the Calculation Agent will calculate a substitute Closing Level for the Index in accordance with the formula for and method of
calculating the Index last in effect prior to the discontinuance, but using only those securities that comprised the Index immediately prior to that discontinuance. If a Successor Equity Index is selected or the Calculation Agent calculates a level
as a substitute for the Index, the Successor Equity Index or level will be used as a substitute for the Index for all purposes, including the purpose of determining whether a Market Disruption Event exists. 

If on the Calculation Day the Index Sponsor fails to calculate and announce the level of the Index, the Calculation
Agent will calculate a substitute Closing Level of the Index in accordance with the formula for and method of calculating the Index last in effect prior to the failure, but using only those securities that comprised the Index immediately prior to
that failure; provided that, if a Market Disruption Event occurs or is continuing on such day, then the provisions set forth above under the definition of “Calculation Day” shall apply in lieu of the foregoing. 

If at any time the Index Sponsor makes a material change in the formula for or the method of calculating the Index, or in any
other way materially modifies the Index (other than a modification prescribed in that formula or method to maintain the Index in the event of changes in constituent stock and capitalization and other routine events), then, from and after that time,
the Calculation Agent will, at the close of business in New York, New York, on each date that 

  
 4 

 
the Closing Level of the Index is to be calculated, calculate a substitute Closing Level of the Index in accordance with the formula for and method of calculating the Index last in effect prior
to the change, but using only those securities that comprised the Index immediately prior to that change. Accordingly, if the method of calculating the Index is modified so that the level of the Index is a fraction or a multiple of what it would
have been if it had not been modified, then the Calculation Agent will adjust the Index in order to arrive at a level of the Index as if it had not been modified. 

Market Disruption Events 

A “Market Disruption Event” means any of the following events as determined by the Calculation Agent in its
sole discretion: 
  

	 	(A)	 The occurrence or existence of a material suspension of or limitation imposed on trading by the Relevant Stock
Exchanges or otherwise relating to securities which then comprise 20% or more of the level of the Index or any Successor Equity Index at any time during the one-hour period that ends at the Close of Trading on that day, whether by reason of
movements in price exceeding limits permitted by those Relevant Stock Exchanges or otherwise. 

  

	 	(B)	 The occurrence or existence of a material suspension of or limitation imposed on trading by any Related
Futures or Options Exchange or otherwise in futures or options contracts relating to the Index or any Successor Equity Index on any Related Futures or Options Exchange at any time during the one-hour period that ends at the Close of Trading on that
day, whether by reason of movements in price exceeding limits permitted by the Related Futures or Options Exchange or otherwise. 

  

	 	(C)	 The occurrence or existence of any event, other than an early closure, that materially disrupts or impairs the
ability of market participants in general to effect transactions in, or obtain market values for, securities that then comprise 20% or more of the level of the Index or any Successor Equity Index on their Relevant Stock Exchanges at any time during
the one-hour period that ends at the Close of Trading on that day. 

  

	 	(D)	 The occurrence or existence of any event, other than an early closure, that materially disrupts or impairs the
ability of market participants in general to effect transactions in, or obtain market values for, futures or options contracts relating to the Index or any Successor Equity Index on any Related Futures or Options Exchange at any time during the
one-hour period that ends at the Close of Trading on that day. 

  

	 	(E)	 The closure on any Exchange Business Day of the Relevant Stock Exchanges on which securities that then
comprise 20% or more of the level of the Index or any Successor Equity Index are traded or any Related Futures or Options Exchange prior to its Scheduled Closing Time unless the earlier closing time is announced by the Relevant Stock Exchange or
Related Futures or Options Exchange, as 

  
 5 

	 	 
applicable, at least one hour prior to the earlier of (1) the actual closing time for the regular trading session on such Relevant Stock Exchange or Related Futures or Options Exchange, as
applicable, and (2) the submission deadline for orders to be entered into the Relevant Stock Exchange or Related Futures or Options Exchange, as applicable, system for execution at such actual closing time on that day. 

 

	 	(F)	 The Relevant Stock Exchange for any security underlying the Index or Successor Equity Index or any Related
Futures or Options Exchange fails to open for trading during its regular trading session. 

 For purposes
of determining whether a Market Disruption Event has occurred: 
  

	 	(1)	 the relevant percentage contribution of a security to the level of the Index or any Successor Equity Index
will be based on a comparison of (x) the portion of the level of such Index attributable to that security and (y) the overall level of the Index or Successor Equity Index, in each case immediately before the occurrence of the Market
Disruption Event; 

  

	 	(2)	 the “Close of Trading” on any Trading Day for the Index or any Successor Equity Index means
the Scheduled Closing Time of the Relevant Stock Exchanges with respect to the securities underlying the Index or Successor Equity Index on such Trading Day; provided that, if the actual closing time of the regular trading session of any such
Relevant Stock Exchange is earlier than its Scheduled Closing Time on such Trading Day, then (x) for purposes of clauses (A) and (C) of the definition of “Market Disruption Event” above, with respect to any security
underlying the Index or Successor Equity Index for which such Relevant Stock Exchange is its Relevant Stock Exchange, the “Close of Trading” means such actual closing time and (y) for purposes of clauses (B) and (D) of the
definition of “Market Disruption Event” above, with respect to any futures or options contract relating to the Index or Successor Equity Index, the “close of trading” means the latest actual closing time of the regular trading
session of any of the Relevant Stock Exchanges, but in no event later than the Scheduled Closing Time of the Relevant Stock Exchanges; 

  

	 	(3)	 the “Scheduled Closing Time” of any Relevant Stock Exchange or Related Futures or Options
Exchange on any Trading Day for the Index or any Successor Equity Index means the scheduled weekday closing time of such Relevant Stock Exchange or Related Futures or Options Exchange on such Trading Day, without regard to after hours or any other
trading outside the regular trading session hours; and 

  

	 	(4)	 an “Exchange Business Day” means any Trading Day for the Index or any Successor Equity Index
on which each Relevant Stock Exchange for the securities underlying the Index or any Successor Equity Index and each Related Futures or Options Exchange are open for trading during their respective regular

  
 6 

	 	 
trading sessions, notwithstanding any such Relevant Stock Exchange or Related Futures or Options Exchange closing prior to its Scheduled Closing Time. 

Calculation Agent 

The Calculation Agent will determine the Redemption Amount and the Ending Level. In addition, the Calculation Agent will
(i) determine if adjustments are required to the Closing Level of the Index under the circumstances described in this Security, (ii) if publication of the Index is discontinued, select a Successor Equity Index or, if no Successor Equity
Index is available, determine the Closing Level of the Index under the circumstances described in this Security, and (iii) determine whether a Market Disruption Event or non-Trading Day has occurred. 

The Company covenants that, so long as this Security is Outstanding, there shall at all times be a Calculation Agent (which
shall be a broker-dealer, bank or other financial institution) with respect to this Security. 

All determinations made by the Calculation Agent with respect to this Security will be at the sole discretion of the
Calculation Agent and, in the absence of manifest error, will be conclusive for all purposes and binding on the Company and the Holder of this Security. 

Tax Considerations 

The Company agrees, and by acceptance of a beneficial ownership interest in this Security each Holder of this Security will be
deemed to have agreed (in the absence of a statutory, regulatory, administrative or judicial ruling to the contrary), for United States federal income tax purposes to characterize and treat this Security as a prepaid derivative contract that is an
“open transaction.” 
 Redemption and Repayment 

This Security is not subject to redemption at the option of the Company or repayment at the option of the Holder hereof prior
to July 11, 2019. This Security is not entitled to any sinking fund. 
 Acceleration 

If an Event of Default, as defined in the Indenture, with respect to this Security shall occur and be continuing, the
Redemption Amount (calculated as set forth in the next sentence) of this Security may be declared due and payable in the manner and with the effect provided in the Indenture. The amount payable to the Holder hereof upon any acceleration permitted
under the Indenture will be equal to the Redemption Amount hereof calculated as provided herein as though the date of acceleration was the Calculation Day. 
  

 

Reference is hereby made to the further provisions of this Security set forth on the reverse hereof, which further provisions
shall for all purposes have the same effect as if set forth at this place. 

  
 7 

 Unless the certificate of authentication hereon has been executed by the Trustee
referred to on the reverse hereof by manual signature or its duly authorized agent under the Indenture referred to on the reverse hereof by manual signature, this Security shall not be entitled to any benefit under the Indenture or be valid or
obligatory for any purpose. 
 [The remainder of this page has been left intentionally blank] 

  
 8 

 IN WITNESS WHEREOF, the Company has caused this instrument to be duly executed
under its corporate seal. 

DATED:                         
      
  

					
	WELLS FARGO & COMPANY
		
	By:	 	 
		
		 	
		 	 Its:
	 	 

 [SEAL] 
  

					
	Attest:	 	 
		
		 	
		 	 Its:
	 	 

 TRUSTEE’S CERTIFICATE OF 

AUTHENTICATION 
 This is one of the Securities of the 

series designated therein described 
 in the within-mentioned Indenture. 
 CITIBANK, N.A., 

as Trustee 
  

			
		
	By:	 	 
		 	 Authorized Signature

 OR 
  

			
	 WELLS FARGO BANK, N.A.,

  as Authenticating Agent for the Trustee

		
	By:	 	 
		 	 Authorized Signature

  
 9 

 [Reverse of Note] 

WELLS FARGO & COMPANY 

MEDIUM-TERM NOTE, SERIES K 

Due Nine Months or More From Date of Issue 

Principal at Risk Securities Linked to the Russell 2000® Index 

due July 11, 2019 

This Security is one of a duly authorized issue of securities of the Company (herein called the
“Securities”), issued and to be issued in one or more series under an indenture dated as of July 21, 1999, as amended or supplemented from time to time (herein called the “Indenture”), between the Company and
Citibank, N.A., as Trustee (herein called the “Trustee,” which term includes any successor trustee under the Indenture), to which Indenture and all indentures supplemental thereto reference is hereby made for a statement of the
respective rights, limitations of rights, duties and immunities thereunder of the Company, the Trustee and the Holders of the Securities, and of the terms upon which the Securities are, and are to be, authenticated and delivered. This Security is
one of the series of the Securities designated as Medium-Term Notes, Series K, of the Company, which series is limited to an aggregate principal amount or face amount, as applicable, of $25,000,000,000 or the equivalent thereof in one or more
foreign or composite currencies. The amount payable on the Securities of this series may be determined by reference to the performance of one or more equity-, commodity- or currency-based indices, exchange traded funds, securities, commodities,
currencies, statistical measures of economic or financial performance, or a basket comprised of two or more of the foregoing, or any other market measure or may bear interest at a fixed rate or a floating rate. The Securities of this series may
mature at different times, be redeemable at different times or not at all, be repayable at the option of the Holder at different times or not at all and be denominated in different currencies. 

Article Sixteen of the Indenture shall not apply to this Security. 

The Securities are issuable only in registered form without coupons and will be either
(a) book-entry securities represented by one or more Global Securities recorded in the book-entry system maintained by the Depositary or (b) certificated
securities issued to and registered in the names of, the beneficial owners or their nominees. 
 The Company agrees, to the
extent permitted by law, not to voluntarily claim the benefits of any laws concerning usurious rates of interest against a Holder of this Security. 

Modification and Waivers 

The Indenture permits, with certain exceptions as therein provided, the amendment thereof and the modification of the rights
and obligations of the Company and the rights of the Holders of the Securities of each series to be affected under the Indenture at any time by the Company and the Trustee with the consent of the Holders of a majority in principal amount of the
Securities at the 

  
 10 

 
time Outstanding of all series to be affected, acting together as a class. The Indenture also contains provisions permitting the Holders of a majority in principal amount of the Securities of all
series at the time Outstanding affected by certain provisions of the Indenture, acting together as a class, on behalf of the Holders of all Securities of such series, to waive compliance by the Company with those provisions of the Indenture. Certain
past defaults under the Indenture and their consequences may be waived under the Indenture by the Holders of a majority in principal amount of the Securities of each series at the time Outstanding, on behalf of the Holders of all Securities of such
series. Solely for the purpose of determining whether any consent, waiver, notice or other action or Act to be taken or given by the Holders of Securities pursuant to the Indenture has been given or taken by the Holders of Outstanding Securities in
the requisite aggregate principal amount, the principal amount of this Security will be deemed to be equal to the amount set forth on the face hereof as the “Face Amount” hereof. Any such consent or waiver by the Holder of this Security
shall be conclusive and binding upon such Holder and upon all future Holders of this Security and of any Security issued upon the registration of transfer hereof or in exchange herefor or in lieu hereof, whether or not notation of such consent or
waiver is made upon this Security. 
 Defeasance 

Section 403 and Article Fifteen of the Indenture and the provisions of clause (ii) of Section 401(1)(B) of the
Indenture, relating to defeasance at any time of (a) the entire indebtedness on this Security and (b) certain restrictive covenants and certain Events of Default, upon compliance by the Company with certain conditions set forth therein,
shall not apply to this Security. The remaining provisions of Section 401 of the Indenture shall apply to this Security. 
 Authorized
Denominations 
 This Security is issuable only in registered form without coupons in denominations of $1,000 or any
amount in excess thereof which is an integral multiple of $1,000. 
 Registration of Transfer 

Upon due presentment for registration of transfer of this Security at the office or agency of the Company in the City of
Minneapolis, Minnesota, a new Security or Securities of this series, with the same terms as this Security, in authorized denominations for an equal aggregate Face Amount will be issued to the transferee in exchange herefor, as provided in the
Indenture and subject to the limitations provided therein and to the limitations described below, without charge except for any tax or other governmental charge imposed in connection therewith. 

This Security is exchangeable for definitive Securities in registered form only if (x) the Depositary notifies the
Company that it is unwilling or unable to continue as Depositary for this Security or if at any time the Depositary ceases to be a clearing agency registered under the Securities Exchange Act of 1934, as amended, and a successor depositary is not
appointed within 90 days after the Company receives such notice or becomes aware of such ineligibility, (y) the Company in its sole discretion determines that this Security shall be exchangeable for definitive Securities in registered form
and notifies the Trustee thereof or (z) an Event of Default with respect to the Securities represented hereby has occurred and is continuing. If this Security is exchangeable pursuant to the preceding sentence, it shall be exchangeable for
definitive Securities in registered 

  
 11 

 
form, having the same date of issuance, Stated Maturity Date and other terms and of authorized denominations aggregating a like amount. 

This Security may not be transferred except as a whole by the Depositary to a nominee of the Depositary or by a nominee of the
Depositary to the Depositary or another nominee of the Depositary or by the Depositary or any such nominee to a successor of the Depositary or a nominee of such successor. Except as provided above, owners of beneficial interests in this Global
Security will not be entitled to receive physical delivery of Securities in definitive form and will not be considered the Holders hereof for any purpose under the Indenture. 

Prior to due presentment of this Security for registration of transfer, the Company, the Trustee and any agent of the Company
or the Trustee may treat the Person in whose name this Security is registered as the owner hereof for all purposes, whether or not this Security be overdue, and neither the Company, the Trustee nor any such agent shall be affected by notice to the
contrary. 
 Obligation of the Company Absolute 

No reference herein to the Indenture and no provision of this Security or the Indenture shall alter or impair the obligation
of the Company, which is absolute and unconditional, to pay the Redemption Amount at the times, place and rate, and in the coin or currency, herein prescribed, except as otherwise provided in this Security. 

No Personal Recourse 

No recourse shall be had for the payment of the Redemption Amount, or for any claim based hereon, or otherwise in respect
hereof, or based on or in respect of the Indenture or any indenture supplemental thereto, against any incorporator, stockholder, officer or director, as such, past, present or future, of the Company or any successor corporation, whether by virtue of
any constitution, statute or rule of law, or by the enforcement of any assessment or penalty or otherwise, all such liability being, by the acceptance hereof and as part of the consideration for the issuance hereof, expressly waived and released.

 Defined Terms 

All terms used in this Security which are defined in the Indenture shall have the meanings assigned to them in the Indenture
unless otherwise defined in this Security. 
 Governing Law 

This Security shall be governed by and construed in accordance with the law of the State of New York, without regard to
principles of conflicts of laws. 

  
 12 

 ABBREVIATIONS 

The following abbreviations, when used in the inscription on the face of this instrument, shall be construed as though they
were written out in full according to applicable laws or regulations: 
  

					
	 TEN COM
	  	 --
	  	 as tenants in common

			
	 TEN ENT
	  	 --
	  	 as tenants by the entireties

			
	 JT TEN
	  	 --
	  	 as joint tenants with right

of survivorship and not
 as
tenants in common

  

							
	
UNIF GIFT MIN ACT --  
	  	 	  	 Custodian  
	  	 
		  	(Cust)	  		  	(Minor)

 Under Uniform Gifts to Minors Act 
  

 
 (State)

 Additional abbreviations may also be used though not in the above list. 

FOR VALUE RECEIVED, the undersigned hereby sell(s) and transfer(s) unto 

Please Insert Social Security or 
 Other Identifying Number of
Assignee 
  
  

 

	
	
	 
	
	 
	
	 
	(PLEASE PRINT OR TYPE NAME AND ADDRESS INCLUDING POSTAL ZIP
CODE OF ASSIGNEE)

  
 13 

 the within Security of WELLS FARGO & COMPANY and does hereby irrevocably constitute and
appoint                                      attorney to
transfer the said Security on the books of the Company, with full power of substitution in the premises. 
  

			
		
	Dated:	 	 
		 	

  

	
	
	 
	
	 

 NOTICE: The signature to this assignment must correspond with the name as written upon the face of the
within instrument in every particular, without alteration or enlargement or any change whatever. 

  
 14EX-10.1

 Exhibit 10.1 

SECOND ADDENDUM TO THE EMPLOYMENT 

CONTRACT DATED 6 OCTOBER 2003 
 BY
AND BETWEEN THE UNDERSIGNED : 
 The company WEIGHT WATCHERS FRANCE, a French
“société à responsabilité limitée”, the registered office of which is located at 7 boulevard des Chênes – parc Ariane – Bâtiment Mars – 78280 Guyancourt, registered with
the business and trade register of Versailles under number 722 063 427 00503, and duly represented by Nicholas Hotchkin in his capacity as Director of Weight Watchers France. 

Hereinafter referred to as the “Company” 

ON ONE HAND, 
 AND 

Mrs. Corinne Pollier-Bousquet, a French citizen, residing [REDACTED], and registered with the social security bodies under number [REDACTED]. 

Hereinafter referred to as the “Employee” 

ON THE OTHER HAND, 
 Together hereinafter referred to as
the « Parties » 
 IT HAS BEEN AGREED
AS FOLLOWS : 
 The present addendum amends the provisions of the Employee’s employment contract
dated 6 October 2003, as amended as from 1 May 2013, with the same object as follows, the remaining terms and conditions of the initial employment contract (as amended in May 2013) remaining unchanged and in force: 

 

	1.	JOB TITLE 

 According to her initial employment contract dated
6 October 2003, the Employee held the position of Managing Director. 
 As per the initial addendum, the Parties agreed that as from 1 May 2013,
the Employee shall perform the duties of “President – Continental Europe”, thus triggering the termination of her functions as Managing Director from that date. 

As per the present addendum, the Parties agreed that, as from 2 March 2016, the Employee shall perform the duties of “President –
International,” thus triggering the termination of her functions as President – Continental Europe from this date. 
 For the execution of her
new duties, the Employee will continue to report to Jim Chambers in his capacity as Chief Executive Officer of Weight Watchers International, Inc, or any other person that may be substituted by the Company. 

2. DUTIES AND RESPONSIBILITIES 

In the frame of her functions as President – International, the Employee will mainly be in charge of the following duties: Management of the United
Kingdom and continental European operational business including (i) contribution to the definition of the strategy of the United Kingdom and Continental Europe and developing such strategy, (ii) day to day supervision of each country
General Manager in the United Kingdom and Continental European countries zone as necessary together with the supervision of the General Manager of Australia; (iii) defining the means and resources necessary for the development of the turnover,
(iv) ensuring clients satisfaction through the respect of the contractual commitments, (v) managing and leading the teams under her responsibility, (vi) defining and implementing operational procedures and (vii) contribution to
international strategy beyond the United Kingdom and Continental Europe. 

 These duties and responsibilities may be modified or changed in order to use in the best way the skills and
abilities of the Employee in light of the Company’s needs and organizational and adaptability objectives. 
 3. WORKING
TIME 
 In the framework of her duties as “ President – International,” the Employee has a high degree of
accountability and benefits from a large autonomy in the performance of her work and in the organisation of her schedule. In addition, she is duly empowered to take decisions involving the Company and classified in the highest level in the Company.
Thus, the Employee is involved in the Company executive management. 
 As a result, the Employee belongs to the category of senior executive status
(“cadres dirigeants”) with the meaning set out in article L. 3111-2 of the French Labour Code. Thus, the Employee is not subject to the provisions of the French Labour Code related to the duration of work, daily rest, bank holidays
and the day of solidarity (“journée de solidarité”). 
 The Employee benefits however from provisions of the French labour
Code regarding paid vacations as well as the time saving account as the case may be. 
 4. PLACE OF WORK

 For information purposes, the Employee’s main place of work is located at 7 boulevard des Chênes – Parc Ariane – Bâtiment
Mars – 78280 Guyancourt. 
 In the framework of the execution of her duties, the Employee shall travel in connection with her employment in France and
abroad. The Employee hereby agrees to travel in connection with her employment for periods that may (accumulatively but not continuously) exceed three months, without constituting a modification of her employment contract. 

However, it is agreed that, considering the nature of the Employee’s activity and the requirements linked with the organization and smooth running of the
Company, the Company may change the Employee’s work place within the administrative areas (“départements”), of the Paris region, subject to a reasonable notice. 

5. REMUNERATION 
 5.1 Base Salary

 In consideration of the performance of her duties, the Employee shall receive an annual salary of a fixed amount of EUR 367,000 gross (the
“Base Salary”) paid in 12 (twelve) equal monthly instalments, i.e. a gross monthly base salary of EUR 30,583.33, from which shall be deducted the social security contributions and other contribution required by law or the applicable
collective bargaining agreements as the case may be. 
 The Employee’s salary is subject to review periodically in compliance with policies applicable
within the Company. 
 5.2 Annual Bonus 
 In addition to
the Base Salary, the Employee shall be entitled to an annual variable remuneration of up to 45% of the annual Base Salary (the “Annual Bonus”). The Annual Bonus may exceed 45%, if the Company decides that it is appropriate to increase the
payment. 
 It is specified that the bonus is awarded at the sole discretion of the Company and is in no way guaranteed from one year to the next, neither
in its principle, its amount nor in the breakdown of its components. 

 5.3 Company car 

The Employee shall benefit from a company car paid by the Company and which annual cost for the Company shall not exceed EUR 17,000 covering car lease payments
as well as associated insurance costs and taxes and the Employee shall pay social charges, contributions and other legal withholdings due by employees on benefits in kind. The Company shall also provide reasonable reimbursement for Employee’s
gasoline and parking expenses. 
 5.4 WWI Stock Incentive Plan 

The Employee will also be eligible to be included in the Weight Watchers International (WWI) Stock Incentive Plan. 

The awards are subject to the continued employment of the Employee and shall be governed by the Weight Watchers International, Inc.’s stock-based
incentive compensation plan documents and relevant agreements. 
 6. NON COMPETE AND NON
SOLICITATION OF CLIENTS 
 Given the extreme sensitivity of the know-how and technical and commercial
information to which the Employee has access in the framework of her duties and the extremely competitive nature of the activities of the Company and the other companies belonging to the Weight Watchers Group, the Parties expressly agree on the
necessity of the non-compete obligation in order to protect the legitimate interests of the Company and the Weight Watchers Group. 
 The Parties agree that
as a result of this non-competition obligation, as from the expiry of the notice period, and in the event of the termination of the Employees’ contract for whatever reasons, the Employee undertakes: 

(i) Not to carry on any business operating in the following countries Austria; Australia; Belgium; Denmark; England; France; Germany; Netherlands;
Northern Ireland; Scotland; Sweden; Spain; Switzerland; or Wales that competes with the following activities: any activities relating to weight loss management through diet and which relates food and nutrition; 

(ii) Not to buy or hold participations in any Person regardless of their seat of incorporation, which carries on, directly or indirectly, the activities listed
under Paragraph (i) proceeding in the countries listed under Paragraph (i); 
 (iii) Not to perform any research and/or development activities, either
for her own account and that of another person including a supplier, customer, university, association, in connection with the products and activities referred to in section (i) above; except in the case of a prior and express agreement from
the Company or the Weight Watchers Group, which could not, in any case, concern such activity for the account of a client; 
 (iv) Nor to act as an
independent consultant / trainer / project development / project management Engineering / in connection with the products and activities referred to in section (i) above. 

In addition, the Employee expressly undertakes : 
 (A) For any
product or activity referred to above, not to visit or contact the Company’s clients or to deal with any individual or company that was a client or a prospect of the Company or any other company of the Weight Watchers Group and with whom the
Employee was in contact at any time during the three years preceding the termination of her employment contract: 
 (B) not to employ or induce to employ or
seek to induce to leave either in her own interest or in the interest of any other Person any employee, specialist/expert, manager or key manager who is an employee or corporate officer of the Company or any other company of the Weight Watchers
Group. 
 This clause will be applied for a six (6)-month period as of the last day of work of the Employee. 

By way of remuneration for this non-compete obligation, and subject to the Employee’s complete compliance with her obligation, she shall receive, for the
duration of the non-compete obligation, a monthly compensation (including corresponding paid leave) in an amount 75% equal to her average gross monthly remuneration calculated over the last 12 months preceding the notification of termination of the
contract. This monthly compensation shall be subject to the social security contributions and other contributions required by law or the applicable collective bargaining agreements, as the case may be. 

The Employee expressly acknowledges that if she does not comply with such obligation, she risks losing the compensation defined above and having to reimburse
to the Company the sums paid in relation to the non-compete obligation, regardless the sanctions and penalties set out hereafter. 

 In case of breach by the Employee of this non-compete obligation, she shall automatically pay to the Company a
penalty which is presently fixed at a flat rate equal to the amount of the monthly compensation stated above. This penalty will be due for each breach, without prior notice to cease the competitive activity. 

The payment of this penalty shall not deprive the Company from its rights to sue the Employee for damages due to the economic and moral harm linked to the
breach by the Employee of her non-compete obligation or from its rights to seek an injunction against the Employee to cease immediately the competitive activity. 

However, the Company shall have the right to waive the non-compete obligation and thus to waive the Employee’s right to the payment of the non-compete
compensation, either at any time during the execution of the employment relationship, or upon the termination of the employment contract. 
 The decision to
waive the non-compete obligation shall be notified to the Employee by registered letter with acknowledgment of receipt, at the latest upon the date of the effective departure of the Employee. 

7. REMAINING TERMS AND CONDITIONS 

The remaining terms and conditions of the initial employment contract entered into between the Employee and the Company on 6 October 2003 which are not
amended by this addendum remain unchanged and in force. 
 8. GOVERNING LAW 

The contract as well as the rights and obligations of the Parties which result there from shall be governed by and construed in accordance with French law. In
the event of a dispute between the Company and the Employee, French jurisdiction shall be competent. 
 9. LANGUAGE 

The present employment contract is drafted in English and French language on which both Parties agree. In case of dispute the English version only shall
prevail. 
 In two originals, one for each Party. 
  

			
	 /s/ Nicholas Hotchkin
	  	May 6, 2016
	For WEIGHT WATCHERS FRANCE*	  	      Date
	Nicholas Hotchkin	  	

 Duly empowered for the purpose hereof 
  

			
	 /s/ Corinne Pollier-Bousquet
	  	May 6, 2016
	Madame Corinne POLLIER-BOUSQUET *	  	      Date

 *Before signing, both Parties handwrite the following: « Read and approved. Good
for 
 agreement on all the terms and conditions included»

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