Download stock option notice of exercise

STOCK OPTION
NOTICE OF EXERCISE
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STOCK OPTION NOTICE OF EXERCISE (To be completed by client)
COMPANY NAME & ADDRESS
STOCK SYMBOL
NO
ATTN (Name of stock option coordinator at company)
I hereby elect to exercise my right to acquire shares (“Shares”) of common stock of the Company as follows:
Number of shares:
______________
Stock option grant dated: ______________
Exercise price:
______________
Trade date:
______________
Payment of
exercise price:
Settlement date:
______________
______________
Sale Price:
______________
Net proceeds to client:
______________
Payment due for
tax withholding:
______________
TOTAL PAYMENT
TO COMPANY:
______________
Piper Jaffray encloses a check(s) made payable to the order of the Company in the above Total Payment amount
representing the exercise price and if applicable the amount payable toward withholding taxes due as a result of the stock
option exercise.
The Shares are to be deposited in my account at Piper Jaffray (Acct. No. _____________________). I hereby instruct you
to issue the shares without a restrictive legend to Piper Jaffray. Piper Jaffray will rely on your representation concerning
my status as an affiliate or non-affiliate of the Company for purposes of Rule 144.
Client Address
Client Signature
Date
X
Print Name
Home Phone
Business Phone
Social Security Number
COMPANY VERIFICATION (To be completed by Piper Jaffray financial advisor)
____________________________________________________ (the “Company”) has verified to Piper Jaffray via telephone
the above information and will deliver to Piper Jaffray within 10 business days (or a reasonable time thereafter) a stock
certificate for the shares.
The client is is not considered an affiliate of the Company for purposes of Rule 144 (if so, call Piper Jaffray
Corporate & Venture Services 612-303-5774).
Print Name of Company Representative
Phone Number
Financial Advisor Signature
Financial Advisor Phone Number
X
DELIVER CERTIFICATES TO PIPER JAFFRAY
Branch Address
City
State
Since 1895. Member SIPC and NYSE.
Form E902 (2/04)
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Please Return to Piper Jaffray
STOCK OPTION
NOTICE OF EXERCISE
STOCK OPTION NOTICE OF EXERCISE (To be completed by client)
COMPANY NAME & ADDRESS
STOCK SYMBOL
NO
ATTN (Name of stock option coordinator at company)
I hereby elect to exercise my right to acquire shares (“Shares”) of common stock of the Company as follows:
Number of shares:
______________
Stock option grant dated: ______________
Exercise price:
______________
Trade date:
______________
Payment of
exercise price:
Settlement date:
______________
______________
Sale Price:
______________
Net proceeds to client:
______________
Payment due for
tax withholding:
______________
TOTAL PAYMENT
TO COMPANY:
______________
Piper Jaffray encloses a check(s) made payable to the order of the Company in the above Total Payment amount
representing the exercise price and if applicable the amount payable toward withholding taxes due as a result of the stock
option exercise.
The Shares are to be deposited in my account at Piper Jaffray (Acct. No. _____________________). I hereby instruct you
to issue the shares without a restrictive legend to Piper Jaffray. Piper Jaffray will rely on your representation concerning
my status as an affiliate or non-affiliate of the Company for purposes of Rule 144.
Client Address
Client Signature
Date
X
Print Name
Home Phone
Business Phone
Social Security Number
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C
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Cli
COMPANY VERIFICATION (To be completed by Piper Jaffray financial advisor)
____________________________________________________ (the “Company”) has verified to Piper Jaffray via telephone
the above information and will deliver to Piper Jaffray within 10 business days (or a reasonable time thereafter) a stock
certificate for the shares.
The client is is not considered an affiliate of the Company for purposes of Rule 144 (if so, call Piper Jaffray
Corporate & Venture Services 612-303-5774).
Print Name of Company Representative
Phone Number
Financial Advisor Signature
Financial Advisor Phone Number
X
DELIVER CERTIFICATES TO PIPER JAFFRAY
Branch Address
City
Form E902 (2/04)
State
Since 1895. Member SIPC and NYSE.
Zip
Client Copy