Fillable Employee Stock Option Intent To Exercise Form printable pdf download

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EMPLOYEE STOCK OPTION INTENT TO EXERCISE

I am a holder of stock options issued by my employer. I wish to exercise these options through the Scottrade, Inc.

(Scottrade) cashless exercise service. I understand that I must have a margin account established to affect this

transaction, the stock must be marginable, and Scottrade will not accept physical delivery of shares. I understand that

Scottrade may not be able to provide this service in all situations.

If Scottrade does agree to exercise my options through this service, I understand that Scottrade will charge me a $50

processing fee, a commission of $32 plus two cents per share, and interest on the credit that Scottrade has advanced to

me in my margin account on the credit terms set forth in the Scottrade

Brokerage and Margin Agreements. These

Agreements are incorporated into this Agreement by reference, and I agree that I have read and understand the terms and

conditions of these Agreements.

I represent that the options were granted to me by my employer, as compensation, and I am currently authorized to

exercise them. I am aware that there may be tax consequences associated with the exercise of employee stock options

and that Scottrade and its employees and agents do not render tax advice. I hold Scottrade harmless from any tax

consequences resulting from this transaction.

I authorize Scottrade to communicate with my employer or its transfer agent regarding all aspects of this transaction. I

understand that the extension of credit for all obligations in relation to the option exercise will result in a debit balance in my

account, and margin interest will be charged from the time Scottrade forwards funds to my employer until Scottrade

receives the shares from my employer. If Scottrade does not receive the shares from the employer, I agree that I am

responsible for continuing interest payments and any losses that Scottrade may incur in not receiving the shares. I

understand that funds from this transaction will not be released until Scottrade is in receipt of the shares from the employer.

I am aware that various federal and state laws or regulations may be applicable to my transactions, and I shall conduct

these transactions in conformity with all applicable laws and regulations. Please check the appropriate box:

I am

I am not

an employee of the employer.

I am

I am not

an officer, director or ten (10) percent shareholder of the employer.

I have

I have not

been told by my employer that I am considered an affiliate of employer as defined

in Rule 144 of the Securities Act of 1933.

I am

I am not

subject to the provisions of Section 16(b) of the Securities Exchange Act of 1934.

aware of any material information concerning my employer that has not been

I am

I am not

publicly disclosed.

NOTICE OF INTENT TO EXERCISE

I hereby give my notice of intent to exercise options granted to me, and I request that Scottrade extend me credit in my

margin account and remit to my employer, the grantor of the options, the aggregate exercise price of the options and

any applicable withholding taxes as specified as follows:

1. Employer Name

2. Stock Symbol

3. Grant Date

4. Number of Shares to Exercise

5. Grant Price

6. Aggregate Exercise Price

7. Withholding Tax

8. Total to Remit to Employer

I authorize and direct Scottrade to sell the number of shares stated above for a $50 processing fee and a commission of

$32 plus two cents per share, and transfer these shares from my employer or employer’s transfer agent to my

Scottrade

margin account.

All the representations that I have made in this Agreement are true and accurate. I understand that Scottrade will rely on

these representations to process this transaction and that I may be held liable for any losses that result from

representations that are false, inaccurate, incomplete or misleading.

Employee Signature

Date

*SF1017*

Print Name

SSN

Signature Page

Signature Verification via

Application

SF1017/11-15

Associate Initials

Scottrade, Inc. - Member

FINRA

and

SIPC

Employee Stock Option Intent To Exercise Form

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