Common use of Acceptance Form Clause in Contracts

Acceptance Form. I have read the Amended and Restated Change of Control Protection Agreement, dated as of January 1, 2012 (“Agreement”) and the accompanying Release [and the information attached as Appendix I] 3 and hereby accept the benefits provided under the Agreement, subject to the terms and conditions set forth in the Agreement and Release. Print Name:______________________ Employee Date:______________________ Signature:________________________ Employee STATE OF NEW YORK ) ) ss: COUNTY OF _________ ) On this ___ day of __________ _______, before me personally came ____________ to be known and known to me to be the person described and who executed the foregoing Release, and (s)he duly acknowledged to me that (s)he executed the same. ________________________ Notary Public

Acceptance Form. I have read the Amended and Restated Change of Control Protection Agreement, dated as of January 1, 2012 (“Agreement”) and the accompanying Release [and the information attached as Appendix I] 3 and hereby accept the benefits provided under the Agreement, subject to the terms and conditions set forth in the Agreement and Release. Print Name:______________________ Employee Date:______________________ Employee Signature:________________________ Employee STATE OF NEW YORK ) ) ss: COUNTY OF _________ ) On this ___ day of __________ _______, before me personally came ____________ to be known and known to me to be the person described and who executed the foregoing Release, and (s)he duly acknowledged to me that (s)he executed the same. ________________________ Notary Public