Document:

Form Long-Term Cash Award Agreement

 Exhibit 10.27 
 PHARMERICA CORPORATION 
 PharMerica Corporation 2007 Omnibus Incentive Plan 
 Long-Term Cash Award Agreement 
 THIS LONG-TERM CASH AWARD AGREEMENT (the “Agreement”), granted under the PharMerica Corporation 2007 Omnibus Incentive Plan (the “Plan”) is effective as of
             200   (the “Date of Grant”) and is made between PharMerica Corporation, a Delaware corporation (the “Company”) and
                     (the “Recipient”). 
 Preliminary Statements 
 WHEREAS, the Company has determined that it is desirable and in its
best interests to grant to the Recipient this long-term cash award, subject to performance conditions, in order to provide the Recipient with a significant interest in the Company’s growth so that the Recipient will have a greater incentive to
perform at the highest level and further the interests of the Company and the shareholders of the Company; and 
 WHEREAS, any
capitalized term not herein defined shall have the meaning as set forth in the Plan. 
 NOW, THEREFORE, in consideration of the mutual
promises and covenants contained herein: 
 1. Grant of Long-Term Cash. On the terms and conditions of this Agreement and
the Plan, the Committee grants to the Recipient a long-term cash award based on the criteria established by the Compensation Committee that are described in Section 2 below (the “Award”). The target Award to be issued is
$             and the maximum Award that may be issued is $            . The extent to which the Award shall become
vested and non-forfeitable shall be determined in accordance with the provisions of Section 2 below. The date of grant of the Award is             ,
20     (the “Grant Date”). 
 The Recipient’s right, if any, to continue to be employed by the
Company will not be enlarged or otherwise affected by the receipt of this Award, and the receipt of this Award will not in any way restrict the right of the Company to terminate the Recipient’s employment at any time. 
 2. Vesting in the Award. Except as provided in Section 3 below, the Recipient shall vest in the Award in accordance with the following
provisions: 
 (a) Performance Cycle. The Performance Cycle for the Award shall commence on the Grant Date and shall end on the
final day of the Company’s 20     fiscal year (December 31, 20    ). 
 (b)
Percentage of Award Earned. Subject to Section 4 below, the extent to which the Award shall become earned at the end of the Performance Cycle shall be based upon the cumulative annual growth in EBITDA (“EBITDA CAGR”) through
the Performance Cycle (the “Performance Criteria”), which shall be determined by taking the Company’s EBITDA for 

 
the Company’s 2007 fiscal year and measuring it against the Company’s EBITDA for the Company’s 2009 fiscal year. The Recipient shall be
entitled to 100% of the Award if the Company has achieved EBITDA CAGR of 20% at the end of the Performance Cycle (equal to a 44% increase in EBITDA by the completion of the Performance Cycle). Generally, the percentage of the Award earned at the end
of the Performance Cycle based on the Performance Criteria shall be determined according to the following schedule, however the actual Award payout will be interpolated between the percentages set forth in the chart based on actual results, as
provided in Exhibit A hereto: 
  

			
	 Performance Criteria
 Target Performance Achievement
	  	 Payout Level
 (percentage of Award earned)

	 < 90%
	  	0%
	 90%
	  	50%
	 100%
	  	100%
	 110%
	  	120%
	 120%
	  	150%
	 > 120%
	  	150%

 (c) Board Certification. Promptly after the Audit Committee of the Board approves the
Company’s financial statements for the fiscal year in which the end of the Performance Cycle occurs, the Committee must determine and certify whether, and to what extent, the Performance Criteria have been achieved. If the minimum
Performance Criteria EBITDA CAGR has not been achieved during the Performance Cycle, the Award will not be paid to the Recipient and this Agreement will be of no force or effect. 
 (d) Vesting. The Recipient shall vest in the Award on the last day of the Performance Cycle (the “Vesting Date”); provided,
however, that, unless otherwise provided in Section 3 below, the Recipient remains in the continuous employment of the Company through the Vesting Date. All vesting in the Award, if applicable, shall occur only on the Vesting Date; there
shall be no proportionate vesting in the Award prior to the Vesting Date. 
 3. Acceleration of Vesting of the Award. Upon the
occurrence of any of the following events, the Recipient shall become fully vested in a pro-rata portion of the Award (as determined under Section 3(c) below: 
 (a) the termination of the Recipient’s employment with the Company by reason of the Recipient’s death or disability (within the meaning of Section 409A of the Code), or the Recipient’s
“Retirement” (as defined in Section 3(d) below) from the Company at or after age 62; or 
  

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 (b) within one (1) year following a Change in Control, (A) the Recipient’s
employment is terminated by the Company without “Cause” (as defined in Section 3(d) below) or (B) the Recipient terminates employment for “Good Reason” (as defined in Section 3(d) below) and provided that the
Recipient executes a non-revocable written release in the form provided by the Company or its successors. 
 (c) Calculation of Pro-Rata
Accelerated Shares. The actual number of Performance Shares that shall be paid upon the occurrence of an event specified in this Section 3 is the amount of Performance Shares as determined and certified under Sections 2(b) and 2(c),
respectively, as if the Recipient were still employed on the Vesting Date, multiplied by a fraction; the numerator of which is the total number of complete months worked by the Recipient during the Performance Cycle, and the denominator of which is
            , the total number of months in the Performance Cycle. 
 (d) Definitions. For purposes hereof, the following definitions shall apply: 
 (i) “Retirement” means a
termination of the Optionee’s employment at or after age 62 for any reason except by the Company for Cause; provided, that the Recipient has been employed by the Company for at least five years 
 (ii) “Good Reason” means: 
 (A) a
reduction of the Recipient’s salary other than (i) a reduction based on the Company’s financial performance, or (ii) a reduction made to the salaries provided to all or most of the other management or executive employees of the
Company with similar responsibilities, positions, compensation or other criteria as determined by the Committee in good faith; 
 (B) a
significant change in the Recipient’s responsibilities and/or duties which constitutes, when compared to the Recipient’s responsibilities and/or duties before the Change of Control, a demotion; or a material loss of title or office; or

 (C) the relocation of the offices at which the Recipient is principally employed as of the Change of Control to a location more than
fifty (50) miles from such offices, which relocation is not approved by the Recipient. 
 (iii) “Cause” means: 
 (A) any willful, material violation of any law or regulation applicable to the business of the Company; 
 (B) conviction for, or guilty plea to, a felony or a crime involving moral turpitude, or any willful perpetration of a common law fraud; 
 (C) commission of any act of personal dishonesty which involves personal profit in connection with the Company; 
  

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 (D) intentional wrongful disclosure of confidential information of the Company; 
 (E) intentional wrongful engagement in any competitive activity, 
 (F) the willful and continued failure or refusal to perform the material duties required of the Recipient as an employee, officer, director or consultant of the Company (other than as a result of disability);

 (G) disregard of the policies of the Company so as to cause material loss, damage or injury to the property, reputation or employees of
the Company; 
 (H) ongoing alcohol/drug addiction and a failure by the Recipient to successfully complete a recovery program, or

 (I) any other misconduct by the Recipient which is materially injurious to the financial condition or business reputation of, or is
otherwise materially injurious to, the Company. 
 4. Forfeiture of the Award. Any portion of the Award that is unvested shall
automatically be forfeited on the date that the Recipient ceases to be employed by the Company. 
 5. Payment of Award. As soon
as administratively practicable after the Vesting Date, but no later than March 15 of the year following the year in which the Vesting Date occurs, the Company shall pay to the Recipient a lump sum equal to the amount earned and certified under
Sections 2(b) and 2(c), respectively. 
 6. Tax Payment Upon Vesting. If the Company is obligated to withhold federal, state
and local income taxes to the extent that the Recipient realizes income in connection with earning and/or being paid any amounts under the terms of this Agreement, then the Recipient agrees that the Company may withhold amounts needed to cover such
taxes from payments otherwise due and owing to the Recipient, and also agrees that upon demand the Recipient will promptly pay to the Company any additional amounts as may be necessary to satisfy such withholding tax obligation. 
 7. Restrictions On Transfer. Other than by will or under the laws of descent and distribution, the Recipient shall not have the right to
make or permit to occur any transfer, pledge or hypothecation of all or any portion of any unvested portion of the Award, whether outright or as security, with or without consideration, voluntary or involuntary. Any such transfer, pledge or
hypothecation not made in accordance with this Agreement shall be deemed null and void. 
 8. Interpretation of this Agreement.
All decisions and interpretations made by the Committee or the Board with regard to any question arising under this Agreement shall be final, binding and conclusive on the Company and the Recipient and any other person entitled to receive the
benefits of the Award as provided for herein. 
  

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 9. Governing Law. The validity, interpretation and enforcement of this Agreement are
governed in all respects by the laws of the State of Delaware, without giving effect to its conflict of laws principles, and by the laws of the United States of America. 
 10. Binding Effect. Subject to all restrictions provided for in this Agreement and by applicable law relating to assignment and transfer of this Agreement and the Award provided for herein, this
Agreement shall be binding upon and inure to the benefit of the parties hereto and their respective heirs, executors, administrators, successors, and assigns. 
 11. Notice. Any notice hereunder by the Recipient to the Company shall be in writing and shall be deemed duly given if mailed or delivered to the Company at its principal office, addressed to the
attention of the Board, or if so mailed or delivered to such other address as the Company may hereafter designate by notice to the Recipient. Any notice hereunder by the Company to the Recipient shall be in writing and shall be deemed duly given if
mailed or delivered to the Recipient at the address specified below by the Recipient for such purpose, or if so mailed or delivered to such other address as the Recipient may hereafter designate by written notice given to the Company. 
 12. Severability. In the event that any one or more of the provisions or portion thereof contained in this Agreement shall for any reason
be held to be invalid, illegal or unenforceable in any respect, the same shall not invalidate or otherwise affect any other provisions of this Agreement, and this Agreement shall be construed as if the invalid, illegal or unenforceable provision or
portion thereof had never been contained herein. 
 13. Entire Agreement. This Agreement constitutes the entire agreement and
supersedes all prior understandings and agreements written or oral, of the parties hereto with respect to the subject matter hereof. There is no representation or statement made by any party on which another party has relied which is not included in
this Agreement. Neither this Agreement nor any term hereof may be amended, waived, discharged, or terminated except by a written instrument signed by the Company and the Recipient; provided, however, that the Company unilaterally may waive any
provision hereof in writing to the extent that such waiver does not adversely affect the interests of the Recipient hereunder, but no such waiver shall operate as or be construed to be a subsequent waiver of the same provision or a waiver of any
other provision hereof. 
  

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 IN WITNESS WHEREOF, the parties hereto have duly executed and delivered this Agreement, or caused
this Agreement to be duly executed and delivered on his or its behalf, as of the day and year first above written. 
  

					
	PHARMERICA CORPORATION	 	
			
	BY:	 	  
	 	
			
	DATE:	 	  
	 	
		
	RECIPIENT	 	
		
	  
	 	
			
	DATE:	 	  
	 	
		
	RECIPIENT’S ADDRESS:	 	
		
	  
	 	
		
	  
	 	
		
	  
	 	

 EXHIBIT AForm Director Restricted Share Award Agreement

 Exhibit 10.28 
 PHARMERICA CORPORATION 
 PharMerica Corporation 2007 Omnibus Incentive Plan 
 Director’s Restricted Share Award Agreement 
 THIS DIRECTOR’S RESTRICTED SHARE AWARD AGREEMENT (the “Agreement”), granted under the PharMerica Corporation 2007 Omnibus Incentive Plan (the “Plan”) is effective as of
             200   (the “Date of Grant”) and is made between PharMerica Corporation, a Delaware corporation (the “Company”) and
                     (the “Recipient”). 
 Preliminary Statements 
 WHEREAS, the Recipient serves as a director on the Company’s
Board of Directors (the “Board”); 
 WHEREAS, the Company has determined that it is desirable and in its best interests to
grant to the Recipient shares of the Company’s common stock (the “Stock”) subject to restrictions, in order to provide the Recipient with a significant equity interest in the Company so that the Recipient will have a greater incentive
to seek to increase the value of the Company’s Stock and so that the Recipient’s interests will be more closely aligned with those of the shareholders of the Company (the “Award”); and 
 WHEREAS, any capitalized term not herein defined shall have the meaning as set forth in the Plan. 
 NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein: 
 1. Grant of Restricted Shares. On the terms and conditions of this Agreement and the Plan, the Company hereby grants to the Recipient
                     shares of Stock (the “Restricted Shares”). The extent to which the Restricted Shares become vested and
non-forfeitable shall be determined in accordance with the provisions of Section 2 of this Agreement. The date of grant of the Restricted Shares is             ,
20     (the “Grant Date”). 
 2. Vesting of the Restricted Shares. The Restricted Shares
granted pursuant to this Agreement shall vest and all restrictions shall lapse thereon as follows: 
 (a) General Vesting Conditions of the
Restricted Shares. Provided that the Recipient continuously serves on the Board through the vesting period, the Restricted Shares shall become vested and all restrictions thereon shall lapse in accordance with the following schedule: 

 

					
	 Vesting Date
	  	 No. of Shares Vested
	  	 Total Percentage of Award Vested

	 1st Anniversary of Grant
Date
	  		  	33 1/3%
	 2nd Anniversary of Grant Date
	  		  	66 2/3%
	 3rd Anniversary of Grant Date
	  		  	100%

 There shall be no proportional vesting prior to a Vesting Date; all vesting shall occur only on the Vesting Date.

 (b) Acceleration of Vesting of the Restricted Shares. The Restricted Shares shall become fully vested and any restrictions thereon
shall automatically lapse upon the occurrence of any of the following events: 
 (i) the termination of the Recipient’s service with the
Company by reason of the Recipient’s death or disability (within the meaning of Section 22(e)(3) of the Code); 
 (ii) provided
that the Recipient is not removed from the Board for “Cause” (as defined in 2(d) below), (A) the Recipient is not nominated for re-election to the Board, or (B) the Recipient is nominated for re-election to the Board but is not
so re-elected; and 
 (iii) a Change in Control. 
 (iv) Notwithstanding the foregoing, the Committee, in its sole and absolute discretion, may accelerate the vesting of and cause all restrictions to lapse on the Restricted Shares at any time. 
 (c) Forfeiture of the Restricted Shares. To the extent that the vesting of the Restricted Shares is not accelerated pursuant to Section 2(b)
above, then the unvested Restricted Shares shall automatically be forfeited on the date that the Recipient ceases to perform services for the Company. 
 (d) Definition of Cause. For purposes hereunder, Cause means: 
 (i) the continued failure by the
Recipient to substantially perform the services expected of a director (other than any such failure resulting from the Recipient’s incapacity due to physical or mental illness or injury) over a period of not less than [thirty (30)] days after a
demand for substantial performance is delivered to the Recipient by the Chairman of the Board or by the chair of the Audit Committee, which demand identifies the manner in which it is believed that the Recipient has not substantially performed the
services expected of the Recipient; 
 (ii) the willful misconduct of the Recipient that is materially and demonstrably injurious to the
Company; provided that no act or failure to act on the Recipient’s part will be considered willful if done, or omitted to be done, by the Recipient in good faith and with reasonable belief that the action or omission was in the best interest of
the Company; 
  

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 (iii) the commission by or indictment of the Recipient for a misdemeanor, which constitutes a crime of
moral turpitude and gives rise to material harm to the Company; or 
 (iv) the commission by or indictment of the Recipient for a felony
(including, without limitation, any felony constituting a crime of moral turpitude). 
 3. Dividends. The Recipient shall have
a right to receive cash dividends, to the extent declared by the Board of Directors, which are paid with respect to the Recipient’s Restricted Shares after the Grant Date until the date on which the Recipient’s interest in such Restricted
Shares has been forfeited. 
 4. Voting Rights. The Recipient shall have a right to vote the Restricted Stock related to his
Award after the Grant Date until the date on which the Recipient’s interest in such Restricted Stock has been forfeited. 
 5.
83(b) Election. The Recipient, having been granted Restricted Stock subject to a “substantial risk of forfeiture,” may elect under Section 83(b) of the Internal Revenue Code of 1986, as amended, to include in his gross
income the fair market value (determined without regard to the restrictions) of such Restricted Stock as of the Grant Date. If the Recipient makes the Section 83(b) election, the Recipient shall (i) make such election in a manner that is
satisfactory to the Company, (ii) provide the Company with a copy of such election, (iii) agree to promptly notify the Company if any Internal Revenue Service or state tax agent, on audit or otherwise, questions the validity or correctness
of such election or of the amount of income reportable on account of such election, and (iv) agree to such federal and state income tax withholding as the Company may reasonably require in its sole and absolute discretion. 
 6. Tax Payment Upon Vesting. 
 (a) At such time as the Recipient becomes vested in the Restricted Shares, the Recipient (or his/her personal representative) shall deliver to the Company, within ten (10) days after the occurrence of the vesting event specified
above (or in the event of death, within ten (10) days of the appointment of the personal representative) (a “Payment Date”), either a check payable to the Company in the amount of all withholding tax obligations (whether federal,
state, local or foreign income or social insurance tax), imposed on the Recipient and the Company by reason of the vesting of the Restricted Shares, or a withholding election form to be provided by the Company upon request by the Recipient (or
personal representative). 
 (b) In the event the Recipient or his personal representative elects to satisfy the withholding
obligation by executing the withholding election form, the Recipient’s actual number of vested shares of Restricted Shares shall be reduced by the smallest number of whole shares of Common Stock of the Company which, when multiplied by the Fair
Market Value of the Common Stock on the Payment Date, is sufficient to satisfy the amount of the withholding tax obligations imposed on the Company by reason of the vesting of the Restricted Shares. In the event that the Recipient fails to tender
either the required certified check or withholding election, the Recipient shall be deemed to have elected and executed the withholding election form. 
  

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 (c) Upon receipt of payment in full of all withholding tax obligations, the Company shall enter
the Recipient (or of such personal representative or administrator of the Recipient’s estate) as the stockholder of record of such released Restricted Shares on the books of the Company. 
 7. Effect of Changes in Capitalization or Change in Control. 
 (a) Changes in Stock. If the outstanding shares of Stock are increased or decreased or changed into or exchanged for a different number or kind of shares or other securities of the Company by reason of any
recapitalization, reclassification, stock split, reverse split, combination of shares, exchange of shares, stock dividend or other distribution payable in capital stock, or other increase or decrease in such shares effected without receipt of
consideration by the Company occurring after the date the Award is granted, then, in the Board’s discretion, a proportionate and appropriate adjustment may be made by the Board in the number and kind of shares subject to the Award, so that the
proportionate interest of the Recipient immediately following such event shall, to the extent practicable, be the same as immediately prior to such event. In the event of any distribution to the Company’s stockholders of securities of any other
entity or other assets (other than dividends payable in cash or stock of the Company) without receipt of consideration by the Company, the Board shall, in such manner as it deems appropriate, adjust the number and kind of shares subject to the Award
to reflect such distribution. 
 (b) Reorganization in Which the Company Is the Surviving Company. Subject to 7(c) below, if the
Company shall be the surviving Company in any reorganization, merger, or consolidation of the Company with one or more other companies or other entities, the Award shall pertain to and apply to the securities to which a holder of the number of
shares of Stock subject to the Award would have been entitled immediately following such reorganization, merger, or consolidation, with a corresponding proportionate adjustment of the Award, as may be applicable so that the aggregate value of the
Award thereafter shall be the same as the aggregate value of the Award immediately before such reorganization, merger, or consolidation. 
 (c) Change in Control. In the event of a Change in Control, the Board may (i) make provisions in connection with such transaction for the continuation of the Award; (ii) reach an agreement with the acquiring or surviving
entity that the acquiring or surviving entity will assume the obligation of the Company under the Award; (iii) reach an agreement with the acquiring or surviving entity that the acquiring or surviving entity will convert the Award into an award
of at least equal value, determined as of the date of the transaction, to purchase stock of the acquiring or surviving entity; or (iv) terminate the Award effective upon the date of the applicable transaction and either make, within sixty
(60) days after the date of the applicable transaction, a cash payment to the Recipient equal to product of the number of shares subject to the Award and the Fair Market Value, as of the date of the applicable transaction, of the shares of
Stock subject to the Award; provided, however, that the Board determines that any such modification does not have a substantial adverse economic impact on the Recipient as determined at the time of such modification. 
 8. General Restrictions. The Company shall not be required to sell or issue any shares of Stock under the Award if the sale or issuance of
such shares would constitute a 

  

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violation by the Recipient or by the Company of any provision of any law or regulation of any governmental authority, including without limitation any
federal or state securities laws or regulations. If at any time the Company shall determine, in its discretion, that the listing, registration, or qualification of any shares subject to the Award upon any securities exchange or under any state or
federal law, or the consent or approval of any government regulatory body, is necessary or desirable as a condition of, or in connection with, the issuance or purchase of shares, the Award may not be exercised in whole or in part unless such
listing, registration, qualification, consent, or approval shall have been effected or obtained free of any conditions not acceptable to the Company, and any delay caused thereby shall in no way affect the date of termination of the Award.
Specifically in connection with the Securities Act of 1933 (as now in effect or as hereafter amended), unless a registration statement under such Act is in effect with respect to the shares of Stock covered by the Award, the Company shall not be
required to sell or issue such shares unless the Company has received evidence satisfactory to it that the holder of the Award may acquire such shares pursuant to an exemption from registration under such Act. Any determination in this connection by
the Company shall be final, binding, and conclusive. The Company may, but shall in no event be obligated to, register any securities covered hereby pursuant to the Securities Act of 1933 (as now in effect or as hereafter amended). The Company shall
not be obligated to take any affirmative action in order to cause the issuance of shares pursuant to the Award to comply with any law or regulation of any governmental authority. As to any jurisdiction that expressly imposes the requirement that the
Award shall not be exercisable unless and until the shares of Stock covered by the Award are registered or are subject to an available exemption from registration, the exercise of the Award (under circumstances in which the laws of such jurisdiction
apply) shall be deemed conditioned upon the effectiveness of such registration or the availability of such an exemption. 
 9.
Restrictions On Transfer. Other than by will or under the laws of descent and distribution, the Recipient shall not have the right to make or permit to occur any transfer, pledge or hypothecation of all or any portion of any unvested
portion of the Award, whether outright or as security, with or without consideration, voluntary or involuntary. Any such transfer, pledge or hypothecation not made in accordance with this Agreement shall be deemed null and void. 
 10. Interpretation of this Agreement. All decisions and interpretations made by the Committee or the Board with regard to any question
arising under this Agreement shall be final, binding and conclusive on the Company and the Recipient and any other person entitled to receive the benefits of the Award as provided for herein. 
 11. Governing Law. The validity, interpretation and enforcement of this Agreement are governed in all respects by the laws of the State of
Delaware, without giving effect to its conflict of laws principles, and by the laws of the United States of America. 
 12. Binding
Effect. Subject to all restrictions provided for in this Agreement and by applicable law relating to assignment and transfer of this Agreement and the Award provided for herein, this Agreement shall be binding upon and inure to the benefit
of the parties hereto and their respective heirs, executors, administrators, successors, and assigns. 
 13. Notice. Any notice
hereunder by the Recipient to the Company shall be in writing and shall be deemed duly given if mailed or delivered to the Company at its principal 

  

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office, addressed to the attention of the Board, or if so mailed or delivered to such other address as the Company may hereafter designate by notice to the
Recipient. Any notice hereunder by the Company to the Recipient shall be in writing and shall be deemed duly given if mailed or delivered to the Recipient at the address specified below by the Recipient for such purpose, or if so mailed or delivered
to such other address as the Recipient may hereafter designate by written notice given to the Company. 
 14. Severability. In
the event that any one or more of the provisions or portion thereof contained in this Agreement shall for any reason be held to be invalid, illegal or unenforceable in any respect, the same shall not invalidate or otherwise affect any other
provisions of this Agreement, and this Agreement shall be construed as if the invalid, illegal or unenforceable provision or portion thereof had never been contained herein. 
 15. Entire Agreement. This Agreement constitutes the entire agreement and supersedes all prior understandings and agreements written or
oral, of the parties hereto with respect to the subject matter hereof. There is no representation or statement made by any party on which another party has relied which is not included in this Agreement. Neither this Agreement nor any term hereof
may be amended, waived, discharged, or terminated except by a written instrument signed by the Company and the Recipient; provided, however, that the Company unilaterally may waive any provision hereof in writing to the extent that such waiver does
not adversely affect the interests of the Recipient hereunder, but no such waiver shall operate as or be construed to be a subsequent waiver of the same provision or a waiver of any other provision hereof. 
  

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 IN WITNESS WHEREOF, the parties hereto have duly executed and delivered this Agreement, or caused
this Agreement to be duly executed and delivered on his or its behalf, as of the day and year first above written. 
  

					
	PHARMERICA CORPORATION	 	
			
	BY:	 	  
	 	
			
	DATE:	 	  
	 	
		
	RECIPIENT	 	
		
	  
	 	
			
	DATE:	 	  
	 	
		
	RECIPIENT’S ADDRESS:

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