Document:

Ex10_09

		
			 
		

		
			 
		

		
			VERASTEM, INC.
		

		
			 
		

		
			Restricted Stock Unit Agreement
		

		
			Granted under 2012 Incentive Plan
		

		
			 
		

		
			NOTICE OF GRANT
		

		
			 
		

		
			This Restricted Stock Unit Agreement (this “Agreement”) is made as of the Agreement Date between Verastem, Inc. (the “Company”), a Delaware corporation, and the Participant.
		

		
			 
		

		
			I. Agreement Date
		

		
			 
		

			
					
						Date:

					
						 

					
					
						[  ]

					
						 

				

		
			   
		

		
			 
		

		
			II. Participant Information
		

		
			 
		

			
					
						Participant:

					
						 

					
					
						[  ]

					
						 

				
	
					
						Participant Address:

					
						 

					
					
						[  ]

					
						 

				
	
					
						 

					
						 

					
					
						 

				

		
			   
		

		
			 
		

		
			III. Grant Information
		

		
			 
		

			
					
						Grant Date:

					
						 

					
					
						[  ]

					
						 

				
	
					
						Restricted Stock Units:

					
						 

					
					
						[  ]

					
						 

				

		
			   
		

		
			 
		

		
			IV. Vesting
		

		
			 
		

		
			Up to [  ]% of the Participant’s Restricted Stock Units shall vest on [  ], provided that the Participant continues to serve as an employee, consultant and/or director of the Company on each such vesting date..
		

		
			 
		

		
			This Agreement includes this Notice of Grant and the following General Terms and Conditions (attached as Exhibit A), which are expressly incorporated by reference in their entirety herein.
		

		
			 
		

		
			IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the Agreement Date.
		

		
			 
		

			
					
						VERASTEM, INC.

					
						 

					
					
						PARTICIPANT

					
						 

				
	
					
						 

					
						 

					
					
						 

					
						 

				
	
					
						By:

					
						 

					
					
						 

					
						 

					
					
						 

					
						 

					
					
						 

					
						 

				

		 

 

	
					
						

					
						Name:

					
						 

					
					
						[  ]

					
						 

					
					
						Name: [  ]

					
						 

				
	
					
						Title:

					
						 

					
					
						[  ]

					
						 

					
					
						 

					
						 

				
	
					
						 

					
					
						 

					
					
						 

					
					
						 

				

		
			   
		

		
			 
		

		
			
		

		
			

		 

 

 
		

		
			Restricted Stock Unit Agreement
		

		
			 
		

		
			EXHIBIT A
		

		
			 
		

		
			GENERAL TERMS AND CONDITIONS
		

		
			 
		

		
			For valuable consideration, receipt of which is acknowledged, the parties hereto agree as follows:
		

		
			 
		

		
			1. Grant of RSUs; Condition of Grant. In consideration of services rendered to the Company by the Participant, the Company has granted to the Participant, subject to the terms and conditions set forth in this Agreement and in the Company’s 2012 Incentive Plan (the “Plan”), an award of Restricted Stock Units (the “RSUs”), representing an award of the number of RSUs (the “Share Number”) set forth in the Notice of Grant that forms part of this Agreement (the “Notice of Grant”). The RSUs entitle the Participant to receive, upon and subject to the vesting of the RSUs (as described in Section 2 below), one share of common stock, $0.0001 par value per share, of the Company (the “Common Stock”) for each RSU that vests. The shares of Common Stock that are issuable upon vesting of the RSUs are referred to in this Agreement as the “Shares.”
		

		
			 
		

		
			2. Vesting of the RSUs; Issuance of Shares.
		

		
			 
		

		
			(a) Vesting of the RSUs. Subject to the other provisions of this Section 2, the RSUs shall vest in accordance with the vesting schedule set forth in the Notice of Grant (the “Vesting Schedule”). Any fractional RSU resulting from the application of the percentages in the Vesting Schedule shall be rounded down to the nearest whole number of RSUs. Within thirty days of each vesting date shown in the Vesting Schedule (the “Vesting Dates”), the Company will issue to the Participant, in certificated or uncertificated form, such number of Shares as is equal to the number of RSUs that vested on such Vesting Date and shall deliver such Shares to the Participant, or to the broker designated by the Participant.
		

		
			 
		

		
			(b) Termination of Relationship with the Company. Except to the extent specifically otherwise provided herein, in the Plan or in another agreement between the Company and the Participant, if the Participant ceases to be an Eligible Participant for any reason, all RSUs that have not vested pursuant to Section 2(a) shall be automatically forfeited as of such termination. For purposes of this agreement, an “Eligible Participant” is an employee, officer or director of, or consultant or advisor to, the Company or any other entity the employees, officers, directors, consultants, or advisors of which are eligible to receive RSU grants under the Plan (an “Eligible Participant”).
		

		
			 
		

		
			3. Change of Control.
		

		
			 
		

		
			If within 90 days prior to a Change of Control or within 18 months following a Change of Control, the Company or any successor thereto terminates the Participant’s employment other than for Cause, or the Participant terminates his or her employment for Good Reason (as defined below), then, each RSU will become exercisable (“vest”) as to 100% of the Shares on the date the Participant’s employment terminates. 
		

		
			 
		

		
			For purposes of this Agreement, “Change of Control” shall mean (i) the acquisition of beneficial ownership (as defined in Rule 13d-3 under the Exchange Act) directly or indirectly by any “person” (as such term is used in Sections 13(d) and 14(d) of the Exchange Act) of securities of the Company representing a majority or more of the combined voting power of the Company’s then outstanding securities, other than an acquisition of securities for investment purposes pursuant to a bona fide financing of the Company; (ii) a merger or consolidation of the Company with any other corporation in which the holders of the voting securities of the Company prior to the merger or consolidation do not own more than 50% of the total voting securities of the surviving corporation; or (iii) the sale or disposition by the Company of all or substantially all of the Company’s assets other than a sale or disposition of assets to an affiliate of the Company or a holder of securities of the Company; notwithstanding the foregoing, no transaction or series of transactions shall constitute a Change of Control unless such transaction or series of transactions constitutes a “change in control event” within the meaning of Treasury Regulation Section 1.409A-3(i)(5)(i).
		

		
			 
		

		
			If the Participant is party to an employment, consulting or severance agreement with the Company that contains a definition of “cause” for termination of employment or other service relationship, “Cause” shall have the meaning ascribed to such term in such agreement.  Otherwise, “Cause” shall mean willful misconduct by the Participant or willful failure by the Participant to perform his or her responsibilities to the Company (including, without limitation, breach by the Participant of any provision of any employment, consulting, advisory, nondisclosure, non-competition or other similar agreement between the Participant and the Company), as determined by the Company, which determination shall be conclusive.  The Participant’s employment or other service relationship shall be considered to have been terminated for 

		 

 

“Cause” if the Company determines, within 30 days after the Participant’s resignation, that termination for Cause was warranted.
		

		
			 
		

		
			If the Participant is party to an employment, consulting or severance agreement with the Company that contains a definition of “good reason” for termination of employment or other service relationship, “Good Reason” shall have the meaning ascribed to such term in such agreement.  Otherwise, “Good Reason” shall mean, without the Participant’s consent, the occurrence of any one or more of the following events: (i) material diminution in the nature or scope of the Participant’s responsibilities, duties or authority, provided that neither (x) the Company’s failure to continue the Participant’s appointment or election as a director or officer of any of its Affiliates nor (y) any diminution in the nature or scope of the Participant’s responsibilities, duties or authority that is reasonably related to a diminution of the business of the Company or any of its affiliates shall constitute “Good Reason”; (ii) a material reduction in the Participant’s base salary other than one temporary reduction of not more than 120 days and not in excess of 20% of the Participant’s base salary in connection with and in proportion to a general reduction of the base salaries of the Company’s executive officers; (iii) failure of the Company to provide the Participant the base salary or benefits owed to the Participant in accordance with his or her employment agreement with the Company, if any, after 30 days’ notice during which the Company does not cure such failure; or (iv) relocation of the Participant’s principal place of business more than forty (40) miles from the then current location of the Participant’s principal place of business.
		

		
			 
		

		
			4. Dividends. The RSUs shall have no rights with respect to dividends declared by the Company with respect to its capital stock, provided that the foregoing shall not prohibit or otherwise limit the adjustment of the terms of this Agreement in accordance with Section 9 of the Plan.
		

		
			 
		

		
			5. Withholding Taxes.
		

		
			 
		

		
			(a) Acknowledgments; No Section 83(b) Election. The Participant acknowledges that he or she is responsible for obtaining the advice of the Participant’s own tax advisors with respect to the grant of the RSUs and the Shares upon vesting thereof and the Participant is relying solely on such advisors and not on any statements or representations of the Company or any of its agents with respect to the tax consequences relating to the RSUs or Shares. The 
		

		
			 
		

		
			
		

		
			

		 

 

 
		

		
			Participant understands that the Participant (and not the Company) shall be responsible for the Participant’s tax liability that may arise in connection with the acquisition, vesting and/or disposition of the RSUs and the Shares underlying the RSUs. The Participant acknowledges that no election under Section 83(b) of the Internal Revenue Code, as amended, is available with respect to the issuance of the RSUs and the Shares underlying the RSUs.
		

		
			 
		

		
			(b) Withholding. As a condition to the granting of the RSUs and the vesting thereof, the Participant acknowledges and agrees that he or she is responsible for the payment of income and employment taxes (and any other taxes required to be withheld) payable in connection with the grant or vesting of, or otherwise in connection with, the RSUs. Accordingly, the Participant agrees to remit to the Company or any applicable subsidiary an amount sufficient to pay such taxes. Such payment shall be made to the Company or the applicable subsidiary of the Company in a form that is reasonably acceptable to the Company, as the Company may determine in its discretion. The Company in its discretion may permit such payment to be made by “net settlement” through which the Company retains and withholds from delivery at the time of vesting that number of shares of Common Stock having a fair market value sufficient to satisfy the applicable tax withholding requirements (but not in excess of the maximum withholding amount consistent with the award being subject to equity accounting treatment under the applicable accounting rules). Alternatively, the Company may require the Participant to provide a designated broker with irrevocable instructions directing the designated broker to, on the date of the designated broker’s receipt of any shares of Common Stock in accordance with Section 2, sell in accordance with ordinary principles of best execution that number of such shares of Common Stock as is necessary to yield net proceeds to the Participant equal to the amount of withholding taxes with respect to the income recognized by the Participant as a result of the vesting of the RSUs (but not in excess of the maximum withholding amount consistent with the award being subject to equity accounting treatment under the applicable accounting rules) and remit such proceeds to the Company in satisfaction of such tax withholding obligations of the Company.
		

		
			 
		

		
			6. Transferability.
		

		
			 
		

		
			(a) Restrictions on Transfer. The Participant shall not sell, assign, transfer, pledge, hypothecate or otherwise encumber, by operation of law or otherwise, any RSUs, or any interest therein, until such RSUs have vested and the Shares underlying the RSUs have been issued.
		

		
			 
		

		
			 
		

		
			 
		

		
			
		

		
			

		 

 

 
		

		
			 
		

		
			 
		

		
			7. Miscellaneous.
		

		
			 
		

		
			(a) No Rights to Employment. The Participant acknowledges and agrees that the grant of the RSUs and their vesting pursuant to Section 2 do not constitute an express or implied promise of continued employment for any period.
		

		
			 
		

		
			(b) Section 409A. This Agreement is intended to comply with or be exempt from the requirements of Section 409A and shall be construed consistently therewith. In any event, the Company makes no representations or warranties and will have no liability to the Participant or to any other person, if any of the provisions of or payments under this Agreement are determined to constitute nonqualified deferred compensation subject to Section 409A but that do not satisfy the requirements of that Section.
		

		
			 
		

		
			(c) Entire Agreement. This Agreement and the Plan constitute the entire agreement between the parties, and supersede all prior agreements and understandings, relating to the subject matter of this Agreement; provided that any separate employment or severance agreement between the Company and the Participant that includes terms relating to the acceleration of vesting of equity awards shall not be superseded by this Agreement. In the event of a conflict between the terms and provisions of the Plan and the terms and provisions of this Agreement, the Plan terms and provisions shall prevail. Capitalized terms used in this Agreement and not otherwise defined herein have the meanings provided for them in the Plan.
		

		
			 
		

		
			(d) Governing Law. This Agreement shall be construed, interpreted and enforced in accordance with the internal laws of the State of Delaware, without regard to any applicable conflict of law principles.
		

		
			 
		

		
			(e) Authority of Compensation Committee. In making any decisions or taking any actions with respect to the matters covered by this Agreement, the Compensation Committee shall have all of the authority and discretion, and shall be subject to all of the protections, provided for in the Plan. All decisions and actions by the Compensation Committee with respect to this Agreement shall be made in the Compensation Committee’s discretion and shall be final and binding on the Participant.Ex10_11

		
			VERASTEM, INC.
		

		
			Nonstatutory Stock Option Agreement
Inducement Award
		

		
			 
		

		
			 
		

			
	
			
				 1.
			Grant of Option.

			
	
			
				 1
			This agreement (this “Agreement”) is made and entered into on [___], 20[___] (the “Grant Date”) by and between Verastem, Inc., a Delaware corporation (the “Company”), and [___] (the “Participant”).  This Agreement evidences an inducement award granted by the Company to the Participant, of an option to purchase, in whole or in part, a total of [___] shares (the “Shares”) of common stock, $0.0001 par value per share, of the Company (“Common Stock”) at $[___] per Share. This option is granted to the Participant in connection with the Participant entering into employment with the Company and is regarded by the parties as an inducement material to the Participant’s entering into employment within the meaning of Nasdaq Listing Rule 5635(c)(4).  Unless earlier terminated, this option shall expire at 5:00 p.m., Eastern Time, on [___] (the “Final Exercise Date”).

			
	
			
				 2
			It is intended that the option evidenced by this Agreement shall not be an incentive stock option as defined in Section 422 of the Internal Revenue Code of 1986, as amended, and any regulations promulgated thereunder (the “Code”). Except as otherwise indicated by the context, the term “Participant”, as used in this option, shall be deemed to include any person who acquires the right to exercise this option validly under its terms.

			
	
			
				 2.
			Relationship to and Incorporation of the 2012 Incentive Plan.  

			
	
			
				 1
			This option shall be subject to and governed by, and shall be construed and administered in accordance with, the terms and conditions of the Company’s 2012 Incentive Plan, as amended from time to time (the “Plan”), which terms and conditions are incorporated herein by reference, except for those terms and conditions contained in Sections 3(c), 4(a), 4(b), 5(b), 6, 7 and 8 of the Plan and any amendments to such sections of the Plan.  Notwithstanding the foregoing, this option is not awarded under the Plan and the grant of this option and issuance of any Shares pursuant to the exercise of this option shall not reduce the number of shares of Common Stock available for issuance under awards pursuant to the Plan.  Capitalized terms in this Agreement have the meanings specified in the Plan, unless a different meaning is specified in this Agreement. 

			
	
			
				 2
			By accepting all or any part of this option the Participant agrees to be bound by the terms and conditions set forth in this Agreement and the Plan, a copy of which has been furnished to the Participant.

			
	
			
				 3.
			Vesting Schedule.

			
	
			
				 1
			This option will become exercisable (“vest”) as to [  ]% of the Shares on [  ], subject to the Participant’s continued employment or other service relationship with the Company on each such vesting date. For purposes of this Agreement, “Vesting Commencement Date” shall mean [___].

		
			

		 

 

		

			
	
			
				 2
			The right of exercise shall be cumulative so that to the extent the option is not exercised in any period to the maximum extent permissible it shall continue to be exercisable, in whole or in part, with respect to all Shares for which it is vested until the earlier of the Final Exercise Date or the termination of this option under Section ‎4 hereof or under the terms of the Plan.

			
	
			
				 4.
			Exercise of Option.

			
	
			
				 (a)
			Form of Exercise. Each election to exercise this option shall be effected by a writing signed by the Participant (whether in the form attached hereto as Exhibit A or in electronic form) and accompanied by payment in full in the manner provided in the Plan. The Participant may purchase less than the number of Shares covered hereby, provided that no partial exercise of this option may be for any fractional share.

			
	
			
				 (b)
			Continuous Relationship with the Company Required. Except as otherwise provided in this Section ‎4, this option may not be exercised unless the Participant, at the time he or she exercises this option, is, and has been at all times since the Grant Date, employed by or otherwise providing services to the Company.

			
	
			
				 (c)
			Termination of Relationship with the Company. If the Participant’s employment or other service relationship ceases for any reason, then, except as provided in paragraphs (d) and (e) below, the right to exercise this option shall terminate three months after such cessation (but in no event after the Final Exercise Date), provided that this option shall be exercisable only to the extent that the Participant was entitled to exercise this option on the date of such cessation. Notwithstanding the foregoing, if the Participant, prior to the Final Exercise Date, violates the non-competition or confidentiality provisions of any employment contract, confidentiality and nondisclosure agreement or other agreement between the Participant and the Company, the right to exercise this option shall terminate immediately upon such violation.

			
	
			
				 (d)
			Exercise Period Upon Death or Disability. If the Participant dies or becomes disabled (within the meaning of Section 22(e)(3) of the Code) prior to the Final Exercise Date while he or she is employed by or otherwise providing services to the Company and the Company has not terminated such employment or other service relationship for “cause” as specified in paragraph (e) below, this option shall be exercisable, within the period of one year following the date of death or disability of the Participant, by the Participant (or in the case of death by an authorized transferee), provided that this option shall be exercisable only to the extent that this option was exercisable by the Participant on the date of his or her death or disability, and further provided that this option shall not be exercisable after the Final Exercise Date.

			
	
			
				 (e)
			Termination for Cause. If, prior to the Final Exercise Date, the Participant’s employment or other service relationship with the Company is terminated by the Company for Cause (as defined below), the right to exercise this option shall terminate immediately upon the effective date of such termination of employment or other service relationship. If, prior to the Final Exercise Date, the Participant is given notice by the Company of the termination of his or her employment or other service relationship by the Company for Cause, and the effective date of such termination is subsequent to the date of the delivery of such notice, the right to exercise this option shall be suspended from the time of the delivery of such notice until the earlier of (i) 

		 

		

			 

		

		

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	such time as it is determined or otherwise agreed that the Participant’s employment or other service relationship shall not be terminated for Cause as provided in such notice or (ii) the effective date of such termination of employment or other service relationship (in which case the right to exercise this option shall, pursuant to the preceding sentence, terminate immediately upon the effective date of such termination of employment or other service relationship). If the Participant is party to an employment, consulting or severance agreement with the Company that contains a definition of “cause” for termination of employment or other service relationship, “Cause” shall have the meaning ascribed to such term in such agreement. Otherwise, “Cause” shall mean willful misconduct by the Participant or willful failure by the Participant to perform his or her responsibilities to the Company (including, without limitation, breach by the Participant of any provision of any employment, consulting, advisory, nondisclosure, non-competition or other similar agreement between the Participant and the Company), as determined by the Company, which determination shall be conclusive. The Participant’s employment or other service relationship shall be considered to have been terminated for “Cause” if the Company determines, within 30 days after the Participant’s resignation, that termination for Cause was warranted.

			
	
			
				 5.
			Change of Control.

		
			If within 90 days prior to a Change of Control or within 18 months following a Change of Control, the Company or any successor thereto terminates the Participant’s employment other than for Cause, or the Participant terminates his or her employment for Good Reason (as defined below), then, this option will become exercisable (“vest”) as to 100% of the Shares on the date the Participant’s employment terminates. 
		

		
			 
		

		
			For purposes of this Agreement, “Change of Control” shall mean (i) the acquisition of beneficial ownership (as defined in Rule 13d-3 under the Exchange Act) directly or indirectly by any “person” (as such term is used in Sections 13(d) and 14(d) of the Exchange Act) of securities of the Company representing a majority or more of the combined voting power of the Company’s then outstanding securities, other than an acquisition of securities for investment purposes pursuant to a bona fide financing of the Company; (ii) a merger or consolidation of the Company with any other corporation in which the holders of the voting securities of the Company prior to the merger or consolidation do not own more than 50% of the total voting securities of the surviving corporation; or (iii) the sale or disposition by the Company of all or substantially all of the Company’s assets other than a sale or disposition of assets to an affiliate of the Company or a holder of securities of the Company; notwithstanding the foregoing, no transaction or series of transactions shall constitute a Change of Control unless such transaction or series of transactions constitutes a “change in control event” within the meaning of Treasury Regulation Section 1.409A-3(i)(5)(i).
		

		
			If the Participant is party to an employment, consulting or severance agreement with the Company that contains a definition of “good reason” for termination of employment or other service relationship, “Good Reason” shall have the meaning ascribed to such term in such agreement.  Otherwise, “Good Reason” shall mean, without the Participant’s consent, the occurrence of any one or more of the following events: (i) material diminution in the nature or scope of the Participant’s responsibilities, duties or authority, provided that neither (x) the Company’s failure to continue the Participant’s appointment or election as a director or officer of 

		 

		

			 

		

		

			-3-

		

 

any of its Affiliates nor (y) any diminution in the nature or scope of the Participant’s responsibilities, duties or authority that is reasonably related to a diminution of the business of the Company or any of its affiliates shall constitute “Good Reason”; (ii) a material reduction in the Participant’s base salary other than one temporary reduction of not more than 120 days and not in excess of 20% of the Participant’s base salary in connection with and in proportion to a general reduction of the base salaries of the Company’s executive officers; (iii) failure of the Company to provide the Participant the base salary or benefits owed to the Participant in accordance with his or her employment agreement with the Company, if any, after 30 days’ notice during which the Company does not cure such failure; or (iv) relocation of the Participant’s principal place of business more than forty (40) miles from the then current location of the Participant’s principal place of business.
		

			
	
			
				 6.
			Withholding.

			
	
			
				 1
			No Shares will be issued pursuant to the exercise of this option unless and until the Participant pays to the Company, or makes provision satisfactory to the Company for payment of, any federal, state or local withholding taxes required by law to be withheld in respect of this option.

			
	
			
				 7.
			Transfer Restrictions.

		
			This option may not be sold, assigned, transferred, pledged or otherwise encumbered by the Participant, either voluntarily or by operation of law, except by will or the laws of descent and distribution or pursuant to a qualified domestic relations order, and, during the lifetime of the Participant, this option shall be exercisable only by the Participant.
		

		
			 
		

		
			 
		

		
			[Remainder of Page Intentionally Left Blank.]
		

		
			
		

		
			

		 

		

			 

		

		

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			IN WITNESS WHEREOF, the Company has caused this option to be executed under its corporate seal by its duly authorized officer. This option shall take effect as a sealed instrument.
		

		
			 
		

			
					
						 

					
					
						VERASTEM, INC.

				
	
					
						 

					
					
						 

					
					
						 

				
	
					
						 

					
					
						 

					
					
						 

				
	
					
						 

					
					
						By:

					
					
						 

				
	
					
						 

					
					
						 

					
					
						 

				
	
					
						 

					
					
						 

					
					
						Name: 

					
					
						 

				
	
					
						 

					
					
						 

					
					
						Title: 

					
					
						 

				

		
			 
		

		
			 
		

		
			PARTICIPANT’S ACCEPTANCE
		

		
			 
		

		
			The undersigned hereby accepts the foregoing option and agrees to the terms and conditions thereof. The undersigned hereby acknowledges receipt of a copy of the Company’s 2012 Incentive Plan.
		

			
					
						 

					
					
						PARTICIPANT:

				
	
					
						 

					
					
						 

				
	
					
						 

					
					
						 

				
	
					
						 

					
					
						 

				
	
					
						 

					
					
						 

				
	
					
						 

					
					
						Address: 

					
					
						 

				
	
					
						 

					
					
						 

					
					
						 

				
	
					
						 

					
					
						 

					
					
						 

				

		
			 
		

		
			
		

		
			

		 

		

			SIGNATURE PAGE TO NONSTATUTORY STOCK OPTION AGREEMENT

		

		

			 

		

		

			 

		

 

		

		
			Notice of Stock Option Exercise
		

		
			 
		

		
			Date:  ___ (1)
		

		
			 
		

		
			Verastem, Inc.
117 Kendrick, Suite 500
Needham, MA 02494
		

		
			Attention: Treasurer
		

		
			 
		

		
			Dear Sir or Madam:
		

		
			 
		

		
			I am the holder of a Nonstatutory Stock Option granted to me as an inducement award subject to the terms and conditions of the Verastem, Inc. 2012 Incentive Plan on ___ (2) for the purchase of ___ (3) shares of Common Stock of the Company at a purchase price of $ ___ (4) per share.
		

		
			I hereby exercise my option to purchase ___ (5) shares of Common Stock, for which I have enclosed ___ (6) in the amount of ___ (7). Please register my stock certificate as follows:
		

		
			 
		

			
					
						Name(s): 

					
					
						 

					
					
						(8)

				
	
					
						 

					
					
						 

					
					
						 

				
	
					
						 

					
					
						 

					
					
						 

				
	
					
						 

					
					
						 

					
					
						 

				
	
					
						Address: 

					
					
						 

					
					
						 

				
	
					
						 

					
					
						 

					
					
						 

				
	
					
						Tax I.D. #: 

					
					
						 

					
					
						(9)

				

		

		
			(1) Enter the date of exercise.
		

		
			(2) Enter the date of grant.
		

		
			(3) Enter the total number of shares of Common Stock for which the option was granted.
		

		
			(4) Enter the option exercise price per share of Common Stock.
		

		
			(5) Enter the number of shares of Common Stock to be purchased upon exercise of all or part of the option.
		

		
			(6) Enter “cash”, “personal check” or if permitted by the option, “stock certificates No. XXXX and XXXX”.
		

		
			(7) Enter the dollar amount (price per share of Common Stock times the number of shares of Common Stock to be purchased), or the number of shares tendered. Fair market value of shares tendered, together with cash or check, must cover the purchase price of the shares issued upon exercise.
		

		
			(8) Enter name(s) to appear on stock certificate: (a) Your name only; (b) Your name and other name (i.e., John Doe and Jane Doe, Joint Tenants With Right of Survivorship); or (c) In the case of a Nonstatutory option only, a Child’s name, with you as custodian (i.e., Jane Doe, Custodian for Tommy Doe). Note: There may be income and/or gift tax consequences of registering shares in a Child’s name.
		

		
			(9) Social Security Number of Holder(s).
		

		
			 
		

		

		 

		

			 

		

		

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						(Signature)

					
					
						 

				

		
			 
		

		
			

		

		 

		

			 

		

		

			-7-

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