Document:

FMC Ex 10.8a 12.31.12

RESTRICTED STOCK UNIT AWARD AGREEMENT 
FMC CORPORATION 
INCENTIVE COMPENSATION AND STOCK PLAN

THIS RESTRICTED STOCK UNIT AWARD AGREEMENT (this “Agreement”) is made by and between FMC Corporation (the “Company”) and (Insert Recipients Name) (the “Participant”).
WHEREAS, the Company maintains the FMC Corporation Incentive Compensation and Stock (the “Plan”); and
WHEREAS, Section 13 of the Plan authorizes the grant of Awards payable in, and valued with reference to, Common Stock; and
WHEREAS, to compensate the Participant for his past and anticipated future contributions to the Company and to further align the Participant’s personal financial interests with those of the Company’s stockholders, the Compensation and Organization Committee of the Company’s Board of Directors approved this grant of restricted stock units to the Participant on the terms described below, effective (Insert Grant Date) (the “Grant Date”).
NOW, THEREFORE, in consideration of the mutual covenants herein contained and other good and valuable consideration, receipt of which is hereby acknowledged, the parties hereto agree as follows:
1.Grant of Restricted Stock Units.
(a)    Pursuant to the Plan and as of the Grant Date, the Company hereby awards to the Participant   (Insert Number of Units) restricted stock units on the terms and conditions set forth herein (the “Units”).  The terms of the Plan are incorporated herein by this reference and made a part of this Agreement.  Capitalized terms not otherwise defined herein will have the same meanings as in the Plan.
(b)    Each Unit, once vested, represents an unfunded, unsecured right of the Participant to receive one share of Common Stock (each a “Share”) at a specified time.  The Units will become vested, and Shares will be issued in respect of vested Units, as set forth in this Agreement.
2.    Vesting.

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(a)    Subject to the Participant’s continued employment by the Company or any of its Affiliates through the applicable date or event, 100% of the Units shall become vested on:
(i)    (Insert Vest Template) (the “Specified Date”) or
(ii)    if sooner, upon:
(A)    the date the Participant has both attained age 62 and completed 10 years of service with the Company and its Affiliates;
(B)    the Participant’s attainment of age 65;
(C)    the Participant’s death;
(D)    the Participant’s Disability;
(E)    the cessation of the Participant’s employment with the Company and its Affiliates within two years following a Change in Control due to either a termination by the Company or an Affiliate without Cause or a resignation by the Employee with Good Reason (as defined in Section 18); or
(F)    the Company’s termination of this arrangement in a manner consistent with the requirements of Treas. Reg. § 1.409A-3(j)(4)(ix).
(b)    In addition, if prior to the date the Units otherwise vest the Participant’s employment is terminated by the Company without Cause other than within two years following a Change in Control, a pro-rata portion of the Units (based on the number of days the Participant was employed by the Company or any of its Affiliates from and after the Grant Date and prior to the Specified Date, relative to the total number of days in the period beginning on the Grant Date and ending on the Specified Date) shall become vested on the effective date of such termination of employment.
(c)    Upon a cessation of the Participant’s employment with the Company or any of its Affiliates, any Unit that has not become vested on or prior to the effective date of such cessation will then be forfeited immediately and automatically and the Participant will have no further rights with respect thereto.
(d)    The application of Sections 2(a)(ii)(E) and 2(b) is in each case conditioned on (i) the Participant’s execution and delivery to the Company of a general release of claims against the Company and its affiliates in a form prescribed by the 

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Company, and (ii) such release becoming irrevocable within 60 days following the cessation of the Participant’s employment or such shorter period specified by the Company.  For avoidance of doubt, if this release requirement is not timely satisfied, the Units will be forfeited as of the effective date of the cessation of the Participant’s employment and the Participant will have no further rights with respect thereto.
3.    Timing of Issuance.
(a)    Subject to Section 3(b), Shares will be issued in respect of all vested Units upon the earliest to occur of:
(i)    the Specified Date;
(ii)    the Participant’s “separation from service” (as that term is defined in Treas. Reg. § 1.409A-1(h)), provided that such separation is due to (A) a termination by the Company or an Affiliate without Cause, (B) a resignation by the Participant with Good Reason within two years following a Change in Control, or (C) the Participant’s Disability, if such condition does not render the Participant “disabled” as that term is defined in Treas. Reg. §§ 1.409A-3(i)(4)(i) and (iii);
(iii)    the Participant Disability, if such condition renders the Participant “disabled” as that term is defined in Treas. Reg. §§ 1.409A-3(i)(4)(i) and (iii);
(iv)    the Participant’s death; or
(v)    the Company’s termination of this arrangement in a manner consistent with the requirements of Treas. Reg. § 1.409A-3(j)(4)(ix).
(b)    Notwithstanding anything herein to the contrary:
(i)    to the extent permitted by Treas. Reg. § 1.409A-3(j)(4)(vi), the issuance of Shares in respect of a number of vested Units will be accelerated to the date that employment taxes become payable with respect to this Award.  Such number of Units will be equal to the reasonably estimated amount of employment taxes then required to be withheld and remitted, divided by the then current Fair Market Value;
(ii)    to the extent the requirements of Treas. Reg. § 1.409A-2(b)(7)(ii) are met, the issuance of Shares hereunder will be delayed to the extent the Company reasonably anticipates that the issuance will violate Federal securities laws or other applicable laws;

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(iii)    to the extent compliance with the requirements of Treas. Reg. § 1.409A-3(i)(2) is necessary to avoid the application of an additional tax under Section 409A of the Code, Shares that are otherwise issuable upon the Grantee’s “separation from service” (as that term is defined in Treas. Reg. § 1.409A-1(h)) will be deferred (without interest) and issued to the Grantee immediately following that six month period; and
(iv)    if the Units vest as a result of the application of Section 2(a)(ii)(E) or 2(b) and the period for the required release to become irrevocable under Section 2(d)(ii) spans two calendar years, Shares will not be issued prior to the start of that second calendar year.
(c)    Fractional Shares will be rounded up to the next whole Share.
4.    Non-Transferability.  Neither the Units nor any right with respect thereto may be assigned, alienated, pledged, attached, sold or otherwise transferred or encumbered by the Participant other than by will or by the laws of descent and distribution, and any purported assignment, alienation, pledge, attachment, sale, transfer or encumbrance will be void and unenforceable against the Company.
5.    Stockholder Rights.
(a)    The Participant will not have any stockholder rights or privileges, including voting or dividend rights, with respect to the Shares subject to Units until such Shares are actually issued and registered in the Participant’s name in the Company’s books and records.
(b)    The foregoing notwithstanding, if the Company declares and pays a cash dividend or distribution with respect to its Common Stock while Units are outstanding hereunder, the Company will make a special cash payment to the Participant equal to the amount of the dividend or distribution that would have been payable to the Participant had he or she been the record holder of a number of Shares equal to the number of Units outstanding hereunder (whether or not vested) on the record date of such dividend or distribution.  Such special cash payment will be paid at the same time as the related dividend or distribution and will be subject to withholding for applicable taxes.
6.    No Limitation on Rights of the Company.  The granting of Units will not in any way affect the right or power of the Company to make adjustments, reclassifications or changes in its capital or business structure or to merge, consolidate, reincorporate, dissolve, liquidate or sell or transfer all or any part of its business or assets.

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7.    Employment.  Nothing in this Agreement or in the Plan will confer on the Participant any right to continue in service for any period of specific duration or interfere with or otherwise restrict in any way the rights of the Company (or Affiliate employing or retaining the Participant) to terminate the Participant’s employment at any time for any reason, with or without cause.
8.    Tax Treatment and Withholding.
(a)    The Participant has had the opportunity to review with his or her own tax advisors the federal, state and local tax consequences of the transactions contemplated by this Agreement.  The Participant is relying solely on such advisors and not on any statements or representations of the Company or any of its agents.
(b)    It is a condition to the Company’s obligation to issue Shares hereunder that the Participant pay to the Company such amount as may be required to satisfy all tax withholding obligations arising in connection with this Award (or otherwise make arrangements acceptable to the Company for the satisfaction of such tax withholding obligations).  If the required withholding amount required is not timely paid or satisfied, the Participant’s right to receive such Shares will be permanently forfeited.  The Company, in its discretion, may withhold Shares otherwise issuable hereunder in satisfaction of the minimum amount required to be withheld in connection with this Award (based on the Fair Market Value of such Shares on the date of such withholding).
9.    Notices.
(a)    Any notice required to be given or delivered to the Company under the terms of this Agreement will be addressed to it in care of its Secretary, FMC Corporation, 1735 Market Street, Philadelphia, PA 19103, and any notice to the Participant (or other person entitled to receive the Units) will be addressed to such person at the Participant’s address now on file with the Company, or to such other address as either may designate to the other in writing.  Except as otherwise provided below in Section 9(b), any notice will be deemed to be duly given when enclosed in a properly sealed envelope addressed as stated above and deposited, postage paid, in a post office or branch post office regularly maintained by the United States government.
(b)    The Participant hereby authorizes the Company to deliver electronically any prospectuses or other documentation related to this Award, the Plan and any other compensation or benefit plan or arrangement in effect from time to time (including, without limitation, reports, proxy statements or other documents that are required to be delivered to participants in such plans or arrangements pursuant to federal or state laws, rules or regulations).  For this purpose, electronic delivery will include, without limitation, delivery by means of e-mail or e-mail notification that such documentation is available on the Company’s Intranet site.  Upon written request, the Company will provide to the Participant a paper copy of any document also delivered to 

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the Participant electronically.  The authorization described in this paragraph may be revoked by the Participant at any time by written notice to the Company.
10.    Beneficiaries.  In the event of the death of the Participant, the issuance of Shares under Section 3 shall be made in accordance with the Participant’s written beneficiary designation on file with the Company (if such a designation has been duly filed with the Company, in the form prescribed by the Company and in accordance with the notice provisions of Section 9(a)).  In the absence of any such beneficiary designation, the delivery of Shares under Section 3 will be made to the person or persons to whom the Participant’s rights shall pass by will or by the applicable laws of intestacy.
11.    Administration.  By entering into this Agreement, the Participant agrees and acknowledges that (a) the Company has provided or made available to the Participant a copy of the Plan, (b) he or she has read the Plan, (c) all Units are subject to the Plan, (d) in the event of a conflict between any term or provision contained herein and a term or provision of the Plan, the applicable terms and provisions of the Plan will govern, and (e) pursuant to the Plan, the Committee is authorized to interpret the Plan and to adopt rules and regulations not inconsistent with the Plan as it deems appropriate.  The Participant hereby agrees to accept as binding, conclusive and final all decisions or interpretations of the Committee with respect to questions arising under the Plan or this Agreement.
12.    Entire Agreement.  This Agreement, together with the Plan, represents the entire agreement between the parties with respect to the subject matter hereof and supersedes any prior agreement, written or otherwise, relating to the subject matter hereof.  This Agreement may only be amended by a writing signed by each of the parties hereto.
13.    Governing Law.  The interpretation, performance and enforcement of this Agreement shall be governed by the laws of the State of Delaware without regard to the principles of conflicts-of-laws.
14.    Privacy.  By signing this Agreement, the Participant hereby acknowledges and agrees to the Company’s transfer of certain personal data of such Participant to the Company for purposes of implementing, performing or administering the Plan or any related benefit.  Participant expressly gives his consent to the Company to process such personal data.
15.    Claims Procedure.
(a)    To the extent the issuance of Shares hereunder is deferred until termination of employment, this Agreement is intended to constitute part of a “top-hat” plan described in Section 201(2) of ERISA.  Therefore, to initiate a claim with respect to the settlement of Units, the Participant (or the person to whom ownership rights may 

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have passed by will or the laws of descent and distribution) (the “Claimant”) must file a written request with the Company.  Upon receipt of such claim, the Company will advise the Claimant within ninety (90) days of receipt of the claim whether the claim is denied.  If special circumstances require more than ninety (90) days for processing, the Claimant will be notified in writing within ninety (90) days of filing the claims than the Company requires up to an additional ninety (90) days to reply.  The notice will explain what special circumstances make an extension necessary and indicate the date a final decision is expected to be made.
(b)    If the claim is denied in whole or in part, the Claimant will be provided a written opinion, in language calculated to be understood by the Claimant, setting forth (i) the specific reason(s) for the denial of the claim, or any part of it, (ii) specific reference(s) to pertinent provisions of the Plan or this Agreement upon which such denial was based, (iii) a description of any additional material or information necessary for the Claimant to perfect the claim, and an explanation of why such material or information is necessary, (iv) an explanation of the claim appeal procedure set forth in Section 15(c), below; and (v) a statement of the Claimant’s right to bring a civil action under section 502(a) of ERISA following an adverse determination upon appeal.
(c)    Within sixty (60) days after receiving a notice from the Company that a claim has been denied, in whole or in part, a Claimant (or the Claimant’s duly authorized representative) may file with the Company a written request for a review of the denial of the claim.  The Claimant or his duly authorized representative may, but need not, review the pertinent documents and submit issues and comments in writing for consideration by the Company.  If the Claimant does not request a review of the initial determination within such sixty (60) days period, the Claimant will be barred and estopped from challenging the determination.
(d)    Within sixty (60) days after the Company’s receipt of a request for review, it will review the initial determination.  After considering all materials presented by the Claimant, without regard to whether such materials were submitted or considered in the initial review, the Company will render a written opinion.  The manner and content of the final decision will include the same information described above in Section 15(b) with respect to the initial determination.  If special circumstances require that the sixty (60) day time period be extended, the Company will so notify the Claimant and will render the decision as soon as possible, but no later than one hundred twenty (120) days after receipt of the request for review.  The notice will explain what special circumstances make an extension necessary and indicate the date a final decision is expected to be made.  Any decision on appeal will be final, conclusive and binding upon all parties.

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16.    Section Headings.  The headings of sections and paragraphs of this Agreement are inserted for convenience only and shall not in any way affect the meaning or construction of any provision of this Agreement.
17.    Counterparts; Facsimile.  This Agreement may be executed in multiple counterparts (including by facsimile signature), each of which will be deemed to be an original, but all of which together will constitute but one and the same instrument.
18.    Good Reason.  For purposes of this Agreement, “Good Reason” will have the meaning defined in the Participant’s Individual Agreement, if any.  If no Individual Agreement exists, “Good Reason” will mean the occurrence of any one or more of the following:
(a)    The assignment to the Participant of duties materially inconsistent with his or her authorities, duties, responsibilities or position, or a material adverse change in the Participant’s authorities, duties, responsibilities, position or reporting requirements;
(b)    The Company’s relocation of the Participant’s principal worksite by more than (50) miles, excepting travel substantially consistent with the Participant’s business obligations; or
(c)    A material reduction in the Participant’s base salary.
provided that any such event will constitute Good Reason only if the Participant notifies the Company in writing of such event within 90 days following the initial occurrence thereof, the Company fails to cure such event within 30 days after receipt from the Participant of written notice thereof, and the Participant resigns his or her Participantemployment within 180 days following the initial occurrence of such event.

[Signature Page Follows.]

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IN WITNESS WHEREOF, the Company’s duly authorized representative and the Participant have each executed this Agreement on the respective date below indicated.

	
		
	FMC CORPORATION

	 
	 

	By:
	 

	Title:
	 

	Date:
	 

	 
	 

	PARTICIPANT

	 
	 

	Signature:
	 

	Address:
	 

	 
	 

	Date:
	 

-9-FMC Ex 10.8b 12.31.12

NONQUALIFIED STOCK OPTION AGREEMENT
PURSUANT TO THE FMC CORPORATION
INCENTIVE COMPENSATION AND STOCK PLAN

This Agreement is made by FMC CORPORATION, a Delaware corporation, (the “Company”) and (Insert Name of Recipient) (the “Employee”).

In 2001, the Board of Directors of the Company (the “Board”) merged the FMC 1995 Management Incentive Plan with and into the FMC 1995 Stock Option Plan and renamed the FMC 1995 Stock Option Plan the FMC Corporation Incentive Compensation and Stock Plan (the “Plan”).  The Plan, as it may be amended and continued, is incorporated by reference and made a part of this Agreement and will control the rights and obligations of the Company and the Employee under this Agreement.  Except as otherwise provided, capitalized terms have the meaning provided in the Plan.  To the extent there is a conflict between the Plan and this Agreement, the Plan will prevail.

The Compensation and Organization Committee of the Board (the “Committee”) determined that it would be to the competitive advantage and interest of the Company and its stockholders to grant a stock option to the Employee as an inducement to remain in the service of the Company or one of its affiliates (collectively, the “Employer”) and as an incentive for increased efforts during such service.

The Committee, on behalf of the Company, has granted to the Employee on the (Insert Grant Date) (the “Grant Date”) a nonqualified stock option (the “Option”) to purchase an aggregate of  (Insert Number of Shares) shares of the common stock of the Company par value of $.10 per share (the “Common Stock”) at a price of (Insert Stock Price) per share upon the following terms and conditions:

1.    Time of Exercise of Option.  Subject to its termination as provided in Section 3, below, and to the satisfaction of the requirements of Section 2 below, 100% of the Option will become exercisable upon the earliest of the following (the “Vesting Date”):

a.the third anniversary of the Grant Date;

b.the date of the Employee’s death;

c.the date of the Employee’s Disability;

d.the date of the Employee’s retirement after he or she (i) has both attained age 62 and completed 10 years of service with the Employer; or (ii) attained age 65 (“Retirement”); or

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e.the cessation of the Employee’s employment with the Employer within two years following a Change in Control due to a termination by the Employer without Cause or a resignation by the Employee with Good Reason (as defined in Section 18), provided (i) the Employee executes and delivers to the Employer a general release of claims against the Company and its affiliates in a form prescribed by the Employer, and (ii) such release becomes irrevocable within 60 days following that cessation or such shorter period specified by the Employer.

Once exercisable, the Option will remain exercisable from time to time, in whole or in part, until terminated in accordance with the Plan or Section 3, below.  This right extends to the Employee or the person or persons to whom the Employee’s rights under the Option pass by will or by the applicable laws of descent and distribution.

2.    Employment.  Subject to Section 3, below, it is a condition precedent to the right to exercise the Option that the Employee remain in the employ of the Employer continuously during the period from the Grant Date to the Vesting Date.  Any portion of the Option that is not vested as of the Employee’s termination of employment with the Employer (including any portion subject to acceleration under Section 1(e) but for which the release requirement is not timely satisfied) will be forfeited as of such termination of employment.

3.    Termination of Option.  The Option and all rights hereunder, to the extent such rights will not have been exercised, will terminate and become null and void on the earliest of (a) (Insert Expiration Date), (b) three months after the date the Employee ceases to be an employee of the Employer for any reason other than death, Disability or Retirement, (c) the fifth anniversary of the Employee’s Retirement or termination due to Disability or death, (d) the date the Employee is terminated for Cause, or (e) if so determined by the Committee, the date of the consummation of a Change in Control, provided the Employee is afforded the opportunity to exercise the Option immediately prior to that Change in Control (such earliest date being referred to as the "Option Expiration Date").

4.    Right to Exercise.  The Option may be exercised at any time on or after the date on which it first becomes exercisable under Sections 1 and 2 above, to and including the Option Expiration Date by the Employee or by the person or persons to whom the Employee's rights under the Option will pass by will or by the applicable laws of descent and distribution.  In no event may the Option be exercised to any extent by anyone before it becomes exercisable pursuant to Sections 1 and 2 above, or after the Option Expiration Date.

5.    Method of Exercise.  The Employee (or other person entitled to do so) may exercise the Option with respect to all or any part of the shares then subject to such exercise (a) by contacting the Company c/o Charles Schwab Corporate Services via website http://eac.schwab.com or telephone 1-800-654-2593, specifying the Grant Date, the number of such shares as to which the Option is being exercised, paying by 

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cash or check, bank draft or postal or express money order payable to the order of the Company in lawful money of the United States an amount equal to the sum of the option price of such shares and the amount of any taxes required to be withheld by the Company (the “Option Payment”) or by shares of Common Stock having a Fair Market Value at the date of such notice equal to the Option Payment or by a combination of cash, check, draft, money order and such shares, and (b) by giving satisfactory assurance in writing that such shares will not be publicly offered for sale, other than on a national securities exchange.  The Company may from time to time make available alternative methods of exercise upon notice to the Employee.  As soon as practicable after receipt of such notice and payment, the Company will, without transfer or issue tax or other incidental expense to the Employee or other person exercising the Option, issue the Common Stock deliverable upon such exercise by causing its transfer agent to make an appropriate book entry in the name of the Employee or other person exercising the Option.

6.    Adjustment.  The Committee may make equitable substitutions or adjustments in the Option and/or Common Stock issuable upon exercise of the Option as it determines to be appropriate in the event of any corporate event or transaction such as a stock split, merger, consolidation, separation, including a spin-off or other distribution of stock or property of the Company, reorganization or any partial or complete liquidation of the Company.

7.    Rights Prior to Exercise.  The Option will during the Employee’s lifetime be exercisable only by the Employee, and neither the Option nor any right thereunder will be assignable or transferable by the Employee by voluntary or involuntary act, operation of law, or otherwise, other than by testamentary bequest or devise or the laws of descent and distribution.  Any effort to assign or transfer a right, except as provided for herein, will be ineffective and may result in the Company terminating the Option.  Neither the Employee nor any other person entitled to exercise the Option will have any of the rights of a stockholder with respect to the shares subject to the Option, except to the extent that Common Stock will have been issued upon the exercise of the Option.

8.    No Limitation on Rights of the Company.  The granting of the Option will not in any way affect the right or power of the Company to make adjustments, reclassifications or changes in its capital or business structure or to merge, consolidate, reincorporate, dissolve, liquidate or sell or transfer all or any part of its business or assets.

9.    Employment.  Nothing in this Agreement or in the Plan will be construed as constituting a commitment, guarantee, agreement or understanding of any kind or nature that the Employer will continue to employ the Employee, or as affecting in any way the right of the Employer to terminate the employment of the Employee at any time.

10.    Government Regulation.  The Company’s obligation to deliver Common Stock upon exercise of the Option will be subject to all applicable laws, rules and 

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regulations and to such approvals by any governmental agencies or national securities exchanges as may be required.

11.    Withholding.  The Employer will comply with all applicable withholding tax laws, and will be entitled to take any action necessary to effectuate such compliance.  

12.    Notice.  Any notice to the Company provided for in this Agreement will be addressed to it in care of its Secretary, FMC Corporation, 1735 Market Street, Philadelphia, PA 19103, and any notice to the Employee (or other person entitled to exercise the Option) will be addressed to the Employee’s address now on file with the Company, or to such other address as either may designate to the other in writing.  Any notice will be deemed to be duly given when enclosed in a properly sealed envelope and addressed as stated above, and deposited, postage paid, in a post office or branch post office regularly maintained by the United States government.

13.Administration.  The Committee administers the Plan.  The Employee’s rights under this Agreement are expressly subject to the terms and conditions of the Plan, a complete copy of which will be sent to you upon your written request to the office of the Vice President of Human Resources.

14.Binding Effect.  This Agreement will inure to the benefit of and be binding upon the parties hereto and their respective heirs, executors, administrators, successors and permitted assigns.

15.Sole Agreement.  This Agreement is the entire agreement between the parties regarding the Option, and any and all prior oral and written representations are merged into this Agreement.  This Agreement may only be amended by written agreement between the Company and the Employee.

16.Governing Law.  The interpretation, performance and enforcement of this agreement will be governed by the laws of the State of Delaware.

17.Discretionary Nature.  The employee acknowledges and agrees that this award is discretionary, and any future awards will be made in the Committee’s discretion; and that the Plan may be terminated, amended or canceled by the Company at any time.

18.Good Reason.  For purposes of this Agreement, “Good Reason” will have the meaning defined in the Employee’s Individual Agreement, if any.  If no Individual Agreement exists, “Good Reason” will mean the occurrence of any one or more of the following:

a.The assignment to the Employee of duties materially inconsistent with his or her authorities, duties, responsibilities or position, or a material adverse 

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change in the Employee’s authorities, duties, responsibilities, position or reporting requirements;

b.The Employer’s relocation of the Employee’s principal worksite by more than (50) miles, excepting travel substantially consistent with the Employee’s business obligations; or

c.A material reduction in the Employee’s base salary.

provided that any such event will constitute Good Reason only if Employee notifies the Employer in writing of such event within 90 days following the initial occurrence thereof, the Employer fails to cure such event within 30 days after receipt from Employee of written notice thereof, and Employee resigns his employment within 180 days following the initial occurrence of such event.

[Signature Page Follows.]

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Each party has executed this Agreement on the date indicated below, respectively.

FMC CORPORATION

	
				
	

By:
	

 /s/ Pierre Brondeau
	 
	 

	 
	Pierre Brondeau
	 
	(Employee)

	 
	Chairman, President and
	 
	 

	 
	Chief Executive Officer
	 
	 

	 
	 
	 
	(Title)

	 
	 
	 
	 

	 
	 
	 
	 

	 
	(Date)
	 
	(Division)

	

	 
	 
	 

	 
	 
	 
	 

	 
	 
	 
	(Address)

	 
	 
	 
	 

	 
	 
	 
	 

	 
	 
	 
	 

	 
	 
	 
	 

	 
	 
	 
	 

	 
	 
	 
	(Date)

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