ASSIGNMENT SEPARATE FROM CERTIFICATE. FOR VALUE RECEIVED, I, _____________________, hereby sell, assign and transfer unto ( ) shares of the Common Stock of Heska Corporation, standing in my name on the books of said corporation represented by Certificate No. herewith and do hereby irrevocably constitute and appoint to transfer said stock on the books of the within-named corporation with full power of substitution in the premises. Dated: , 20 .
ASSIGNMENT SEPARATE FROM CERTIFICATE. FOR VALUE RECEIVED, _____________hereby assigns and transfers unto Xxxxxxx Education, Inc., a Maryland corporation (the "Corporation"), ____________(__________) shares of common stock of the Corporation represented by Certificate No. ___ herewith and does hereby irrevocably constitute and appoint _______________________ as Attorney to transfer the said stock on the books of the Corporation with full power of substitution in the premises. Dated:____________, ______ Print Name Signature Spouse Consent (if applicable) ___________________ (Purchaser's spouse) indicates by the execution of this Assignment his or her consent to be bound by the terms herein as to his or her interests, whether as community property or otherwise, if any, in the shares of common stock of the Corporation. Signature INSTRUCTIONS: PLEASE DO NOT FILL IN ANY BLANKS OTHER THAN THE SIGNATURE LINE. THE PURPOSE OF THIS ASSIGNMENT IS TO ENABLE THE CORPORATION TO CANCEL YOUR UNVESTED SHARES AS SET FORTH IN THE AGREEMENT WITHOUT REQUIRING ADDITIONAL SIGNATURES ON THE PART OF PURCHASER. EXHIBIT C ELECTION UNDER SECTION 83(b) OF THE INTERNAL REVENUE CODE The undersigned hereby makes an election pursuant to Section 83(b) of the Internal Revenue Code with respect to the property described below and supplies the following information in accordance with the regulations promulgated thereunder:
ASSIGNMENT SEPARATE FROM CERTIFICATE. FOR VALUE RECEIVED, hereby sells, assigns and transfers unto Flotek Industries, Inc., a Delaware corporation (the “Company”), ( ) shares of common stock of the Company represented by Certificate No. and does hereby irrevocably constitute and appoint , or his designee or successor, as attorney to transfer the said stock on the books of the Company with full power of substitution in the premises. Dated: , 20 . Print Name Signature INSTRUCTIONS: PLEASE DO NOT FILL IN ANY BLANKS OTHER THAN THE SIGNATURE LINE. THE PURPOSE OF THIS ASSIGNMENT IS TO ENABLE THE COMPANY TO EXERCISE ITS “REPURCHASE OPTION” SET FORTH IN THE AWARD AGREEMENT WITHOUT REQUIRING ADDITIONAL SIGNATURES ON THE PART OF THE PURCHASER.
ASSIGNMENT SEPARATE FROM CERTIFICATE. FOR VALUE RECEIVED (“Purchaser”) hereby sells, assigns and transfers unto FLURRY, INC., a Delaware corporation (the “Company”), ( ) shares of Common Stock of the Company represented by Certificate No. herewith and does hereby irrevocably constitute and appoint Attorney to transfer the said stock on the books of the Company with full power of substitution in the premises. Dated: , 20 . Signature Spousal Consent (Purchaser’s spouse) indicates by the execution of this Assignment his or her consent to be bound by the terms herein as to his or her interests, whether as community property or otherwise, if any, in the Shares. Signature PURCHASER TO SIGN ONLY ON THE SIGNATURE LINE WITHOUT COMPLETION OF ANY OTHER BLANK SPOTS ON THE ASSIGNMENT. THE PURPOSE OF THIS ASSIGNMENT IS TO ENABLE THE COMPANY TO EXERCISE ITS “REPURCHASE OPTION” SET FORTH IN THE STOCK OPTION AGREEMENT AND STOCK OPTION PLAN WITHOUT REQUIRING ADDITIONAL SIGNATURES ON THE PART OF PURCHASER. EXHIBIT D FLURRY, INC. AMENDED AND RESTATED 2005 STOCK OPTION PLAN INVESTMENT REPRESENTATION STATEMENT In connection with the purchase of shares of Flurry, Inc. (the “Corporation”) Common Stock, the undersigned, (the “Optionee”) represents to the Corporation the following:
ASSIGNMENT SEPARATE FROM CERTIFICATE. FOR VALUE RECEIVED, Xxxxxx Xxxxxx Xxxxxx (“Executive”) does hereby sell, assign and transfer unto ________________, a ______________, _____________ shares of __________________ of Capella Holdings, Inc., a Delaware corporation (the “Company”), standing in the undersigned’s name on the books of the Company represented by Stock Certificate Nos. _________________ herewith and does hereby irrevocably constitute and appoint each principal of GTCR Xxxxxx Xxxxxx, L.L.C. or GTCR Xxxxxx Xxxxxx XX, L.L.C. (acting alone or with one or more other such principals) as attorney to transfer the said securities on the books of the Company with full power of substitution in the premises. This Assignment Separate from Certificate may be used only for purposes of or in connection with transfers made in connection with Section 3 of that certain Senior Management Agreement among the Company, Capella Healthcare, Inc., a Delaware corporation, and Executive, dated as of October ___, 2005, as amended from time to time pursuant to its terms, or Section 4 of that certain Stockholders Agreement, among the Company, Executive and certain stockholders of the Company, dated as of May 4, 2005, as amended from time to time pursuant to its terms. Dated: ____________________ ________________________________________ Xxxxxx Xxxxxx Xxxxxx EXHIBIT D SPOUSAL CONSENT The undersigned spouse of Executive hereby acknowledges that I have read the foregoing Senior Management Agreement and the Registration Agreement and the Stockholders Agreement referred to therein, each executed by Executive and dated as of the date hereof, and that I understand their contents. I am aware that the foregoing Senior Management Agreement and the Stockholders Agreement provide for the repurchase of my spouse’s Executive Securities under certain circumstances and/or impose other restrictions on such securities (including, without limitation, restrictions on transfer). I agree that my spouse’s interest in these securities is subject to these restrictions and any interest that I may have in such securities shall be irrevocably bound by these agreements and further, that my community property interest, if any, shall be similarly bound by these agreements. _____________________________ Date: __________, 2005 Spouse’s Name _______________________ _____________________________ Date: __________, 2005 Witness’ Name _______________________
ASSIGNMENT SEPARATE FROM CERTIFICATE. FOR VALUE RECEIVED the undersigned does hereby sell, assign and transfer unto _________________________ _____________________ (_________________) shares of the Common Stock of JDA SOFTWARE GROUP, INC. standing in the undersigned's name on the books of said corporation represented by Certificate No. __________________ herewith and does hereby irrevocably constitute and appoint ______________________ Attorney to transfer the said stock on the books of said corporation with full power of substitution in the premises. Dated: __________________________________ ___________________________________ Signature ___________________________________ Print Name Instructions: Please do not fill in any blanks other than the signature line. The purpose of this assignment is to enable the Company to exercise its Company Reacquisition Right set forth in the Restricted Stock Agreement without requiring additional signatures on the part of the Participant.
ASSIGNMENT SEPARATE FROM CERTIFICATE. FOR VALUE RECEIVED, I, _____________________, hereby sell, assign and transfer unto _____________________________________________________________ (______) shares of the Common Stock of Heska Corporation, standing in my name on the books of said corporation represented by Certificate No. _____ herewith and do hereby irrevocably constitute and appoint ______________________________ _____________________ to transfer said stock on the books of the within-named corporation with full power of substitution in the premises. Dated: ____________, 20___. Signature: This Assignment Separate from Certificate was executed in conjunction with the terms of a Restricted Stock Grant Agreement between the above assignor and Heska Corporation, dated __________ __, 2015. Instruction: Please do not fill in any blanks other than the signature line.
ASSIGNMENT SEPARATE FROM CERTIFICATE. FOR VALUE RECEIVED, I, _____________________, hereby sell, assign and transfer unto (____________) shares of the Common Stock of Heska Corporation, standing in my name on the books of said corporation represented by Certificate No. ________ herewith and do hereby irrevocably constitute and appoint to transfer said stock on the books of the within-named corporation with full power of substitution in the premises. Dated: _____________ __, 20__. Signature: This Assignment Separate from Certificate was executed in conjunction with the terms of a Restricted Stock Grant Agreement between the above assignor and Heska Corporation, dated __________ __, 2014. Instruction: Please do not fill in any blanks other than the signature line. HESKA CORPORATION 1997 STOCK INCENTIVE PLAN RESTRICTED STOCK GRANT AGREEMENT THIS AGREEMENT is made as of the _________ day of ____________, 2014 by and between Heska Corporation (the "Company"), and Xxxxxx X. Xxxxxx (the "Executive"), in connection with the execution of an Employment Agreement dated on or about the same date between the Company and Executive (the "Employment Agreement"). In consideration of the mutual covenants and representations herein set forth, the Company and Executive agree as follows:
ASSIGNMENT SEPARATE FROM CERTIFICATE. FOR VALUE RECEIVED, _____________hereby assigns and transfers unto Strategic Education, Inc., a Maryland corporation (the "Corporation"), ____________(__________) shares of common stock of the Corporation represented by Certificate No. ___ herewith and does hereby irrevocably constitute and appoint _______________________ as Attorney to transfer the said stock on the books of the Corporation with full power of substitution in the premises. Dated: , Print Name Signature Spouse Consent (if applicable) ___________________ (Purchaser's spouse) indicates by the execution of this Assignment his or her consent to be bound by the terms herein as to his or her interests, whether as community property or otherwise, if any, in the shares of common stock of the Corporation.
ASSIGNMENT SEPARATE FROM CERTIFICATE. FOR VALUE RECEIVED, hereby assigns and transfers unto Strategic Education, Inc., a Maryland corporation (the “Corporation”), ( ) shares of common stock of the Corporation represented by Certificate No. herewith and does hereby irrevocably constitute and appoint as Attorney to transfer the said stock on the books of the Corporation with full power of substitution in the premises. Dated: , Print Name Signature Spouse Consent (if applicable) (Purchaser’s spouse) indicates by the execution of this Assignment his or her consent to be bound by the terms herein as to his or her interests, whether as community property or otherwise, if any, in the shares of common stock of the Corporation.
