Document:

Form of Performance Shares Award

 EXHIBIT 10.2.3 
 NEXX SYSTEMS, INC. 
 2011 EQUITY INCENTIVE PLAN 

NOTICE OF PERFORMANCE SHARES AWARD 
 GRANT NUMBER:              
 Unless otherwise defined herein, the terms defined in the NEXX Systems, Inc. (the “Company”) 2011 Equity Incentive Plan (the “Plan”) shall have the same
meanings in this Notice of Performance Shares Award (the “Notice”). 
  

			
	Name:	 	 
		
	Address:	 	 

 You (“Participant”) have
been granted an award of Performance Shares under the Plan subject to the terms and conditions of the Plan, this Notice and the attached Performance Shares Award Agreement (hereinafter “Performance Shares Agreement”).

  

			
		
	Number of Shares:	  	 
		
	Date of Grant:	  	 
		
	Vesting Commencement Date: 	  	 
		
	Expiration Date:	  	The date on which all the Shares granted hereunder become vested, with earlier expiration upon the Termination Date
		
	Vesting Schedule:	  	Subject to the limitations set forth in this Notice, the Plan and the Performance Shares Agreement, the Shares will vest in accordance with the following
schedule:
		
		  	[INSERT VESTING SCHEDULE / PERFORMANCE FACTORS]

You understand that your employment or consulting relationship or service with the Company is for an unspecified duration, can be terminated at any time
(i.e., is “at-will”), and that nothing in this Notice, the Performance Shares Agreement or the Plan changes the at-will nature of that relationship. You acknowledge that the vesting pursuant to this Notice is earned only upon the
applicable certification of attainment of the requisite Performance Factors enumerated above while still in service as an Employee, Director or Consultant of the Company. You also understand that this Notice is subject to the terms and conditions of
both the Performance Shares Agreement and the Plan, both of which are incorporated herein by reference. Participant has read both the Performance Shares Agreement and the Plan. 

 

									
	PARTICIPANT 	 		 	NEXX SYSTEMS, INC.
					
	Signature:	 	 	 		 	Signature:	 	 
	Print Name:	 	 	 		 	Print Name:	 	 
	Date:	 	 	 		 	Title:	 	 
		 		 		 	Date:	 	 

 NEXX SYSTEMS, INC. 

2011 EQUITY INCENTIVE PLAN 
 PERFORMANCE SHARES AGREEMENT 
 Unless otherwise defined herein, the terms defined in the
NEXX Systems, Inc. (the “Company”) 2011 Equity Incentive Plan (the “Plan”) shall have the same defined meanings in this Performance Shares Agreement (the “Agreement”).

 Participant has been granted a Performance Shares Award (“Performance Shares Award”) subject to the terms,
restrictions and conditions of the Plan, the Notice of Performance Shares Award (“Notice”) and this Agreement. 
 1.
Settlement. The Performance Shares Award shall be settled in Shares, and the Company’s transfer agent shall record ownership of such Shares in Participant’s name as soon as reasonably practicable after achievement of the
Performance Factors enumerated in the Notice. 
 2. Stockholder Rights. Participant shall have no right to dividends or to vote
Shares until Participant is recorded as the holder of such Shares on the stock records of the Company and its transfer agent. 
 3. No
Transfer. Participant’s interest in this Performance Shares Award shall not be sold, assigned, transferred, pledged, hypothecated, or otherwise disposed of. 
 4. Termination. Upon Participant’s Termination for any reason, all of Participant’s rights under the Plan, this Agreement and the Notice in respect of this Award shall immediately
terminate. In case of any dispute as to whether Termination has occurred, the Committee shall have sole discretion to determine whether such Termination has occurred and the effective date of such Termination. 

5. U.S. Tax Consequences. Participant acknowledges that there will be tax consequences upon issuance of the Shares, and Participant should
consult a tax adviser regarding Participant’s tax obligations prior to such settlement or disposition. Upon vesting of the Shares, Participant will include in income the fair market value of the Shares. The included amount will be treated as
ordinary income by Participant and will be subject to withholding by the Company when required by applicable law. Before any Shares subject to this Agreement are issued the Company shall withhold a number of Shares with a fair market value
(determined on the date the Shares are issued) equal to the minimum amount the Company is required to withhold for income and employment taxes. Upon disposition of the Shares, any subsequent increase or decrease in value will be treated as
short-term or long-term capital gain or loss, depending on whether the Shares are held for more than one year from the date of issuance. 

6. Acknowledgement. The Company and Participant agree that the Performance Shares Award is granted under and governed by the Notice, this
Agreement and by the provisions of the Plan (incorporated herein by reference). Participant: (i) acknowledges receipt of a copy of the Plan and the Plan prospectus, (ii) represents that Participant has carefully read and is familiar with
their provisions, and (iii) hereby accepts the Performance Shares Award subject to all of the terms and conditions set forth herein and those set forth in the Plan, this Agreement and the Notice. 

7. Entire Agreement; Enforcement of Rights. This Agreement, the Plan and the Notice constitute the entire agreement and understanding of
the parties relating to the subject matter herein and supersede all prior discussions between them. Any prior agreements, commitments or negotiations concerning the purchase of the Shares hereunder are superseded. No modification of or amendment to
this Agreement, nor any waiver of any rights under this Agreement, shall be effective unless in writing and signed by the parties to this Agreement. The failure by either party to enforce any rights under this Agreement shall not be construed as a
waiver of any rights of such party. 
 8. Compliance with Laws and Regulations. The issuance of Shares will be
subject to and conditioned upon compliance by the Company and Participant with all applicable state and federal laws and regulations and with all applicable requirements of any stock exchange or automated quotation system on which the Company’s
Common Stock may be listed or quoted at the time of such issuance or transfer. The Company reserves the right to impose other requirements on your participation in the Plan, on the Performance Shares Award and on any shares of Common Stock acquired
under the Plan, to the extent the Company determines it is necessary or advisable in order to comply with local law or facilitate the administration of the Plan, and to require you to sign any additional agreements or undertakings that may be
necessary to accomplish the foregoing. 

 9. Governing Law; Severability. If one or more provisions of this Agreement are held
to be unenforceable under applicable law, the parties agree to renegotiate such provision in good faith. In the event that the parties cannot reach a mutually agreeable and enforceable replacement for such provision, then (i) such provision
shall be excluded from this Agreement, (ii) the balance of this Agreement shall be interpreted as if such provision were so excluded and (iii) the balance of this Agreement shall be enforceable in accordance with its terms. This Agreement
and all acts and transactions pursuant hereto and the rights and obligations of the parties hereto shall be governed, construed and interpreted in accordance with the laws of the State of Delaware, without giving effect to principles of conflicts of
law. 
 10. No Rights as Employee, Director or Consultant. Nothing in this Agreement shall affect in any
manner whatsoever the right or power of the Company, or a Parent or Subsidiary of the Company, to terminate
Purchaser’s service, for any reason, with or without
cause. 
 By Participant’s signature and the signature of the Company’s representative on the Notice, Participant and
the Company agree that this Performance Shares Award is granted under and governed by the terms and conditions of the Plan, the Notice and this Agreement. Participant has reviewed the Plan, the Notice and this Agreement in their entirety, has had an
opportunity to obtain the advice of counsel prior to executing this Agreement, and fully understands all provisions of the Plan, the Notice and this Agreement. Participant hereby agrees to accept as binding, conclusive and final all decisions or
interpretations of the Committee upon any questions relating to the Plan, the Notice and this Agreement. Participant further agrees to notify the Company upon any change in Participant’s residence address.Form of Restricted Stock Award Agreement

 EXHIBIT 10.2.4 
 NEXX SYSTEMS, INC. 
 2011 EQUITY INCENTIVE PLAN 

NOTICE OF RESTRICTED STOCK AWARD 
 GRANT NUMBER:              
 Unless otherwise defined herein, the terms defined in the NEXX Systems, Inc. (the “Company”) 2011 Equity Incentive Plan (the “Plan”) shall have the same
meanings in this Notice of Restricted Stock Award (the “Notice”). 
  

			
	Name:	 	 
		
	Address: 	 	 

 You (“Participant”) have
been granted an award of Restricted Shares of Common Stock of NEXX Systems, Inc. under the Plan subject to the terms and conditions of the Plan, this Notice and the attached Restricted Stock Agreement (the “Restricted Stock
Agreement”). 
  

			
		
	 Total Number of Restricted Shares Awarded:
	  	  

		
	 Fair Market Value per Restricted Share:
	  	$________________________________________________________
		
	 Total Fair Market Value of Award:
	  	$________________________________________________________
		
	 Purchase Price per Restricted Share:
	  	$________________________________________________________
		
	 Total Purchase Price for all Restricted Shares:
	  	$________________________________________________________
		
	 Date of Grant:
	  	  

		
	 Vesting Commencement Date:
	  	  

		
	 Vesting Schedule:
	  	Subject to the limitations set forth in this Notice, the Plan and the Restricted Stock Agreement, the Restricted Shares will vest and the right of repurchase shall lapse, in
whole or in part, in accordance with the following schedule:
		
		  	[INSERT VESTING SCHEDULE]

 You understand that your
employment or consulting relationship with the Company is for an unspecified duration, can be terminated at any time (i.e., is “at-will”), and that nothing in this Notice, the Restricted Stock Agreement or the Plan changes the at-will
nature of that relationship. You acknowledge that the vesting of the Restricted Shares pursuant to this Notice is earned only by continuing service as an Employee, Director or Consultant of the Company. You also understand that this Notice is
subject to the terms and conditions of both the Restricted Stock Agreement and the Plan, both of which are incorporated herein by reference. You have read both the Restricted Stock Agreement and the Plan. If the Restricted Stock Agreement is not
executed by you within thirty (30) days of the Date of Grant above, then this grant shall be void. 
  

									
	PARTICIPANT 	 		 	NEXX SYSTEMS, INC.
					
	Signature:	 	 	 		 	Signature:	 	 
	Print Name:	 	 	 		 	Print Name:	 	 
	Date:	 	 	 		 	Title:	 	 
		 		 		 	Date:	 	 

 NEXX SYSTEMS, INC. 

2011 EQUITY INCENTIVE PLAN 
 RESTRICTED STOCK AGREEMENT 
 THIS RESTRICTED STOCK AGREEMENT (this
“Agreement”) is made as of                      , 20     by and between NEXX Systems, Inc.,
a Delaware corporation (the “Company”), and                      (“Participant”) pursuant to
the Company’s 2011 Equity Incentive Plan (the “Plan”). Unless otherwise defined herein, the terms defined in the Plan shall have the same meanings in this Agreement. 

1. Sale of Stock. Subject to the terms and conditions of this Agreement, on the Purchase Date (as defined below) the
Company will issue and sell to Participant, and Participant agrees to purchase from the Company the number of Shares shown on the Notice of Restricted Stock Award (the “Notice”) at a purchase price of $ per Share.
The per Share purchase price of the Shares shall be not less than the par value of the Shares as of the date of the offer of such Shares to Participant. The term “Shares” refers to the purchased Shares and all securities received in
replacement of or in connection with the Shares pursuant to stock dividends or splits, all securities received in replacement of the Shares in a recapitalization, merger, reorganization, exchange or the like, and all new, substituted or additional
securities or other properties to which Participant is entitled by reason of Participant’s ownership of the Shares. 

2. Time and Place of Purchase. The purchase and sale of the Shares under this Agreement shall occur at the principal office
of the Company simultaneously with the execution of this Agreement by the parties, or on such other date as the Company and Participant shall agree (the “Purchase Date”). On the Purchase Date, the Company will issue in
Participant’s name a stock certificate representing the Shares to be purchased by Participant against payment of the purchase price therefor by Participant by (a) check made payable to the Company, (b) cancellation of indebtedness of
the Company to Participant, (c) Participant’s personal services that the Committee has determined have already been rendered to the Company and have a value not less than aggregate par value of the Shares to be issued Participant, or
(d) a combination of the foregoing. 
 3. Restrictions on Resale. By signing this Agreement, Participant
agrees not to sell any Shares acquired pursuant to the Plan and this Agreement at a time when applicable laws, regulations or Company or underwriter trading policies prohibit exercise or sale. This restriction will apply as long as Participant is
providing service to the Company or a Subsidiary of the Company. 
 3.1 Repurchase Right on
Termination. For the purposes of this Agreement, a “Repurchase Event” shall mean an occurrence of one of the following: 
 (i) termination of Participant’s service, whether voluntary or involuntary and with or without cause; 
 (ii) resignation, retirement or death of Participant; or 

(iii) any attempted transfer by Participant of the Shares, or any interest therein, in violation of this Agreement.

 Upon the occurrence of a Repurchase Event, the Company shall have the right (but not an obligation) to purchase the Shares of Participant at
a price equal to the Purchase Price per Share (the “Repurchase Right”). The Repurchase Right shall lapse in accordance with the vesting schedule set forth in the Notice. For purposes of this Agreement, “Unvested
Shares” means Stock pursuant to which the Company’s Repurchase Right has not lapsed. 
 3.2
Exercise of Repurchase Right. Unless the Company provides written notice to Participant within 90 days from the date of termination of Participant’s service to the Company that the Company does not intend to exercise its Repurchase
Right with respect to some or all of the Unvested Shares, the Repurchase Right shall be deemed automatically exercised by the Company as of the 90th day following such termination, provided that the Company may notify Participant that it is
exercising its Repurchase Right as of a date prior to such 90th day. Unless Participant is otherwise notified by the Company pursuant to the preceding sentence that the Company does not intend to exercise its Repurchase Right as to some or all of
the Unvested Shares, execution of this Agreement by Participant constitutes written notice to Participant of the Company’s intention to exercise its Repurchase Right with respect to all Unvested Shares to which such Repurchase Right applies at
the time of Termination of Participant. The 

 
Company, at its choice, may satisfy its payment obligation to Participant with respect to exercise of the Repurchase Right by either (A) delivering a check to Participant in the amount of
the purchase price for the Unvested Shares being repurchased, or (B) in the event Participant is indebted to the Company, canceling an amount of such indebtedness equal to the purchase price for the Unvested Shares being repurchased, or
(C) by a combination of (A) and (B) so that the combined payment and cancellation of indebtedness equals such purchase price. In the event of any deemed automatic exercise of the Repurchase Right by canceling an amount of such
indebtedness equal to the purchase price for the Unvested Shares being repurchased, such cancellation of indebtedness shall be deemed automatically to occur as of the 90th day following termination of Participant’s employment or consulting
relationship unless the Company otherwise satisfies its payment obligations. As a result of any repurchase of Unvested Shares pursuant to the Repurchase Right, the Company shall become the legal and beneficial owner of the Unvested Shares being
repurchased and shall have all rights and interest therein or related thereto, and the Company shall have the right to transfer to its own name the number of Unvested Shares being repurchased by the Company, without further action by Participant.

 3.3 Acceptance of Restrictions. Acceptance of the Shares shall constitute Participant’s
agreement to such restrictions and the legending of his or her certificates with respect thereto. Notwithstanding such restrictions, however, so long as Participant is the holder of the Shares, or any portion thereof, he or she shall be entitled to
receive all dividends declared on and to vote the Shares and to all other rights of a stockholder with respect thereto. 
 3.4 Non-Transferability of Unvested Shares. In addition to any other limitation on transfer created by applicable securities laws or any other agreement between the Company and Participant,
Participant may not transfer any Unvested Shares, or any interest therein, unless consented to in writing by a duly authorized representative of the Company. Any purported transfer is void and of no effect, and no purported transferee thereof will
be recognized as a holder of the Unvested Shares for any purpose whatsoever. Should such a transfer purport to occur, the Company may refuse to carry out the transfer on its books, set aside the transfer, or exercise any other legal or equitable
remedy. In the event the Company consents to a transfer of Unvested Shares, all transferees of Shares or any interest therein will receive and hold such Shares or interest subject to the provisions of this Agreement, including, insofar as
applicable, the Repurchase Right. In the event of any purchase by the Company hereunder where the Shares or interest are held by a transferee, the transferee shall be obligated, if requested by the Company, to transfer the Shares or interest to
Participant for consideration equal to the amount to be paid by the Company hereunder. In the event the Repurchase Right is deemed exercised by the Company, the Company may deem any transferee to have transferred the Shares or interest to
Participant prior to their purchase by the Company, and payment of the purchase price by the Company to such transferee shall be deemed to satisfy Participant’s obligation to pay such transferee for such Shares or interest, and also to satisfy
the Company’s obligation to pay Participant for such Shares or interest. 
 3.5 Assignment.
The Repurchase Right may be assigned by the Company in whole or in part to any persons or organization. 
 4.
Restrictive Legends and Stop Transfer Orders. 
 4.1 Legends. The certificate or
certificates representing the Shares shall bear the following legend (as well as any legends required by applicable state and federal corporate and securities laws): 
 THE SHARES REPRESENTED BY THIS CERTIFICATE MAY BE TRANSFERRED ONLY IN ACCORDANCE WITH THE TERMS OF AN AGREEMENT BETWEEN THE COMPANY AND THE STOCKHOLDER, A COPY OF WHICH IS ON FILE WITH THE SECRETARY OF
THE COMPANY. 
 4.2 Stop-Transfer Notices. Participant agrees that, in order to ensure compliance
with the restrictions referred to herein, the Company may issue appropriate “stop transfer” instructions to its transfer agent, if any, and that, if the Company transfers its own securities, it may make appropriate notations to the same
effect in its own records. 
 4.3 Refusal to Transfer. The Company shall not be required
(i) to transfer on its books any Shares that have been sold or otherwise transferred in violation of any of the provisions of this Agreement or (ii) to treat as the owner or to accord the right to vote or pay dividends to any purchaser or
other transferee to whom such Shares shall have been so transferred. 

 5. No Rights as Employee, Director or Consultant. Nothing
in this Agreement shall affect in any manner whatsoever the right or power of the Company, or a Parent or Subsidiary of the Company, to terminate Participant’s service, for any reason, with or without cause. 

6. Miscellaneous. 
 6.1 Acknowledgement. The Company and Participant agree that the Restricted Shares are granted under and governed by the Notice, this Agreement and by the provisions of the Plan (incorporated
herein by reference). Participant: (i) acknowledges receipt of a copy of the Plan and the Plan prospectus, (ii) represents that Participant has carefully read and is familiar with their provisions, and (iii) hereby accepts the
Restricted Shares subject to all of the terms and conditions set forth herein and those set forth in the Plan and the Notice. 
 6.2 Entire Agreement; Enforcement of Rights. This Agreement, the Plan and the Notice constitute the entire agreement and understanding of the parties relating to the subject matter herein
and supersede all prior discussions between them. Any prior agreements, commitments or negotiations concerning the purchase of the Shares hereunder are superseded. No modification of or amendment to this Agreement, nor any waiver of any rights under
this Agreement, shall be effective unless in writing and signed by the parties to this Agreement. The failure by either party to enforce any rights under this Agreement shall not be construed as a waiver of any rights of such party. 

6.3 Compliance with Laws and Regulations. The issuance of Shares will be subject to and conditioned upon
compliance by the Company and Participant with all applicable state and federal laws and regulations and with all applicable requirements of any stock exchange or automated quotation system on which the Company’s Common Stock may be listed or
quoted at the time of such issuance or transfer. The Company reserves the right to impose other requirements on your participation in the Plan or on the Shares, to the extent the Company determines it is necessary or advisable in order to comply
with local law or facilitate the administration of the Plan, and to require you to sign any additional agreements or undertakings that may be necessary to accomplish the foregoing. 

6.4 Governing Law; Severability. If one or more provisions of this Agreement are held to be unenforceable
under applicable law, the parties agree to renegotiate such provision in good faith. In the event that the parties cannot reach a mutually agreeable and enforceable replacement for such provision, then (i) such provision shall be excluded from
this Agreement, (ii) the balance of this Agreement shall be interpreted as if such provision were so excluded and (iii) the balance of this Agreement shall be enforceable in accordance with its terms. This Agreement and all acts and
transactions pursuant hereto and the rights and obligations of the parties hereto shall be governed, construed and interpreted in accordance with the laws of the State of Delaware, without giving effect to principles of conflicts of law. 

6.5 Construction. This Agreement is the result of negotiations between and has been reviewed by each of the
parties hereto and their respective counsel, if any; accordingly, this Agreement shall be deemed to be the product of all of the parties hereto, and no ambiguity shall be construed in favor of or against any one of the parties hereto. 

6.6 Notices. Any notice to be given under the terms of the Plan shall be addressed to the Company in care of
its principal office, and any notice to be given to Participant shall be addressed to such Participant at the address maintained by the Company for such person or at such other address as Participant may specify in writing to the Company.

 6.7 Counterparts. This Agreement may be executed in two or more counterparts, each of which
shall he deemed an original and all of which together shall constitute one instrument. 
 6.8 U.S. Tax
Consequences. Upon vesting of Shares, Participant will include in taxable income the difference between the fair market value of the vesting Shares, as determined on the date of their vesting, and the price paid for the Shares. This will be
treated as ordinary income by Participant and will be subject to withholding by the Company when required by applicable law. In the absence of an Election (defined below), the Company shall withhold a number of vesting Shares with a fair market
value (determined on the date of their vesting) equal to the minimum amount the Company is required to withhold for income and employment taxes. If Participant makes an Election, then Participant must, prior to making the Election, pay in cash (or
check) to the Company an amount equal to the amount the Company is required to withhold for income and employment taxes. 

 7. Section 83(b) Election. Participant hereby acknowledges that he or she has
been informed that, with respect to the purchase of the Shares, an election may be filed by Participant with the Internal Revenue Service, within 30 days of the purchase of the Shares, electing pursuant to Section 83(b) of the Code to be taxed
currently on any difference between the purchase price of the Shares and their Fair Market Value on the date of purchase (the “Election”). Making the Election will result in recognition of taxable income to Participant
on the date of purchase, measured by the excess, if any, of the Fair Market Value of the Shares over the purchase price for the Shares. Absent such an Election, taxable income will be measured and recognized by Participant at the time or times on
which the Company’s Repurchase Right lapses. Participant is strongly encouraged to seek the advice of his or her own tax consultants in connection with the purchase of the Shares and the advisability of filing of the Election. PARTICIPANT
ACKNOWLEDGES THAT IT IS SOLELY PARTICIPANT’S RESPONSIBILITY, AND NOT THE COMPANY’S RESPONSIBILITY, TO TIMELY FILE THE ELECTION UNDER SECTION 83(b) OF THE CODE, EVEN IF PARTICIPANT REQUESTS THE COMPANY, OR ITS REPRESENTATIVE, TO MAKE
THIS FILING ON PARTICIPANT’S BEHALF. 
 The parties have executed this Agreement as of the date first set forth above.

  

			
	NEXX SYSTEMS, INC.
		
	By:	 	 
	Print Name:	 	 
	Title:	 	 

  

			
	RECIPIENT:
		
	Signature:	 	 
	Print Name:	 	 

 RECEIPT 
 NEXX Systems, Inc. hereby acknowledges receipt of (check as applicable): 
  ̈    A check in the amount of $              
  ̈    The cancellation of indebtedness in the amount of $
             
 given by
             as consideration for Certificate No.-             for
                     shares of Common Stock of NEXX Systems, Inc. 
 Dated:                      

 

			
	NEXX SYSTEMS, INC.
		
	By:	 	 
	Print Name:	 	 
	Title:	 	 

 RECEIPT AND CONSENT

 The undersigned Participant hereby acknowledges receipt of a photocopy of Certificate No.-
             for shares                      of Common Stock of NEXX
Systems, Inc. (the “Company”). 
 The undersigned further acknowledges that the Secretary of the
Company, or his or her designee, is acting as escrow holder pursuant to the Restricted Stock Agreement that Participant has previously entered into with the Company. As escrow holder, the Secretary of the Company, or his or her designee, holds the
original of the aforementioned certificate issued in the undersigned’s name. To facilitate any transfer of Shares to the Company pursuant to the Restricted Stock Agreement, Participant has executed the attached Stock Power and Assignment
Separate from Certificate. 
 Dated:
                     
  

			
	Signature	 	 
	Please Print Name	 	 

 STOCK POWER AND  

ASSIGNMENT SEPARATE FROM CERTIFICATE  
 FOR VALUE RECEIVED and pursuant to that certain Restricted Stock Agreement dated as of
                     (the “Agreement”), the undersigned Participant hereby sells, assigns and transfers unto
                    ,              shares of the Common Stock, $0.0001 par
value per share, of NEXX Systems, Inc., a Delaware corporation (the “Company”), standing in the undersigned’s name on the books of the Company represented by Certificate No(s).
             delivered herewith, and does hereby irrevocably constitute and appoint the Secretary of the Company as the undersigned’s attorney-in-fact, with full power of
substitution, to transfer said stock on the books of the Company. THIS ASSIGNMENT MAY ONLY BE USED AS AUTHORIZED BY THE AGREEMENT AND ANY EXHIBITS THERETO. 
 Dated:                      

 

	
	PARTICIPANT
	
	  
	(Signature)
	
	  
	(Please Print Name)

 Instructions to
Participant: Please do not fill in any blanks other than the signature and print name lines. The purpose of this document is to enable the Company and/or its assignee(s) to acquire the shares upon exercise of its “Repurchase Right”
set forth in the Agreement without requiring additional action by Participant.

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