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EXHIBIT 99.12
COM21, INC.
1998 EMPLOYEE STOCK PURCHASE PLAN ("ESPP")
ENROLLMENT/CHANGE FORM
Action Complete Sections:
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[ ] New Enrollment 2, 3, 7, 8 and sign attached
SECTION 1: Stock Purchase
ACTIONS Agreement
[ ] Payroll Deduction Change 2, 4, 8
[ ] Terminate Payroll Deductions 2, 5, 8
[ ] Leave of Absence 2, 6, 8
[ ] Beneficiary Change 2, 7, 8
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SECTION 2: Name
PERSONNEL -----------------------------------------------------------
DATA Last First MI Dept.
Home or Mailing Address
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Street
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City State Zip Code
Social Security #: - -
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SECTION 3: Effective with the Purchase
NEW Interval Beginning:
ENROLLMENT [ ] May ___, 199___
[ ] November ___, 199___
[ ] Initial Offering Period May, 1998
Amount to be deducted
(circle one): 1% 2% 3% 4% 5% 6% 7% 8% 9% 10%
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SECTION 4: Effective on or as soon as practicable after the Pay Period
CHANGE Beginning:
PAYROLL ----------------------------------------------------
DEDUCTIONS
Amount to be deducted
(circle one): 1% 2% 3% 4% 5% 6% 7% 8% 9% 10%
NOTE: You may reduce your rate of payroll deductions once per 6-month
purchase interval to become effective as soon as possible
following the filing of the change form. You may increase your
rate of payroll deductions to become effective as of the start
date of the next 6-month purchase interval (May 1 or
November 1).
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SECTION 5: Effective with the Pay Period Beginning:
TERMINATE ----------------------
PAYROLL Month, Day and Year
DEDUCTIONS
Your election to terminate your payroll deductions for the
balance of the offering period must be received by the Stock
Administration Dept. at least one (1) business day prior to the
applicable purchase date, and you may not rejoin that offering
period at a later date. You will not be able to resume
participation in the ESPP until a new offering period begins.
In connection with my voluntary termination of payroll
deductions, I elect the following action regarding my ESPP
payroll deductions to date in the current purchase interval:
[ ] Purchase shares of Com21, Inc. on next scheduled
purchase date
OR
[ ] Refund ESPP payroll deductions collected
NOTE: If your employment terminates for any reason or your
eligibility status changes (less than 20 hrs/wk or less than 5
months/yr), you will immediately cease to participate in the
ESPP, and your ESPP payroll deductions collected in that
purchase interval will automatically be refunded to you.
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SECTION 6: In connection with my unpaid leave of absence, I elect the
LEAVE OF following action with respect to my ESPP payroll deductions to
ABSENCE date:
in the current offering period:
[ ] Purchase shares of Com21, Inc. on next scheduled
purchase date
OR
[ ] Refund ESPP payroll deductions collected
NOTE: If you take an unpaid leave of absence, your payroll deductions
will immediately cease.
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SECTION 7: Beneficiary Relationship of Beneficiary
BENEFICIARY ----------- ---------------------------
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SECTION 8:
AUTHORIZATION
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Date Signature of Employee
