Common use of Attestation Form Clause in Contracts

Attestation Form. As indicated above, I have elected to use shares of Pacific Financial Corporation common stock that I already own to pay the Aggregate Purchase Price of the Option (and withholding taxes, if applicable). I attest to the ownership of the shares represented by the certificate(s) listed below or to the beneficial ownership of the shares held in the name of my broker, as indicated in the attached copy of my brokerage statement. I will be deemed to have delivered such shares to Pacific in connection with the exercise of my Option. I understand that, because I (and any joint owner) will retain ownership of the shares (the "Payment Shares") deemed delivered to pay the Aggregate Purchase Price (and withholding taxes, if applicable), the number of shares to be issued to me upon exercise of my Option will be reduced by the number of Payment Shares. I represent that I have full power to deliver and convey certificates representing the Payment Shares to Pacific and by such delivery and conveyance could have caused Pacific to become sole owner of the Payment Shares. The joint owner of the Payment Shares, if any, by signing this Form, consents to these representations and to the exercise of the Option by this attestation. I certify that the Payment Shares have not been used or acquired in a stock-for-stock exercise of any option within the six months preceding the exercise of this Option. I also certify that, if the Payment Shares were acquired by me upon exercise of a stock option or as restricted shares, (a) I have held the Payment Shares for at least six months, and (b) any Payment Shares originally issued to me as restricted shares are now fully vested. List certificate(s) and number of shares covered, or attach a copy of your brokerage statement: Common Stock Certificate Number Number of Shares Covered Date: Print Name of Option Holder: Signature of Option Holder: Print Name of Joint Owner: Signature of Joint Owner: If you are attaching a copy of your brokerage statement, you must have your securities broker complete the following: The undersigned hereby certifies that the foregoing attestation is correct. Name of Brokerage Firm Date: By: Telephone No.: Print Name of Signing Broker

Appears in 2 contracts

Samples: Nonqualified Stock Option Agreement (Pacific Financial Corp), Incentive Stock Option Agreement (Pacific Financial Corp)

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Attestation Form. As indicated above, I have elected to use shares of Pacific Financial Corporation BBSI common stock that I already own to pay the Aggregate Purchase Option Price of the Option (and withholding taxes, if applicable)Option. I attest to the ownership of the shares represented by the certificate(s) listed below or to the beneficial ownership of the shares held in the name of my broker, as indicated in the attached copy of my brokerage statement. I will be deemed to have delivered such shares to Pacific BBSI in connection with the exercise of my Option. I understand that, because I (and any joint owner) will retain ownership of the shares (the "Payment Shares") deemed delivered to pay the Aggregate Purchase Price (and withholding taxes, if applicable)Option Price, the number of shares to be issued to me upon exercise of my Option will be reduced by the number of Payment Shares. I represent that I have full power to deliver and convey certificates representing the Payment Shares to Pacific BBSI and by such delivery and conveyance could have caused Pacific BBSI to become sole owner of the Payment Shares. The joint owner of the Payment Shares, if any, by signing this Form, consents to these representations and to the exercise of the Option by this attestation. I certify that the Payment Shares have not been used or acquired in a stock-for-stock exercise of any option within the six months preceding the exercise of this Option. I also certify that, if the Payment Shares were acquired by me upon exercise of a stock option or as restricted shares, (a) I have held the Payment Shares for at least six months, and (b) any Payment Shares originally issued to me as restricted shares are now fully vested. List certificate(s) and number of shares covered, or attach a copy of your brokerage statement: Common Stock Certificate Number Number of Shares Covered Date: Print Name of Option Holder: Signature of Option Holder: Print Name of Joint Owner: Signature of Joint Owner: If you are attaching a copy of your brokerage statement, you must have your securities broker complete the following: The undersigned hereby certifies that the foregoing attestation is correct. Name of Brokerage Firm Date: By: Telephone No.: Print Name of Signing Broker

Appears in 1 contract

Samples: Award Agreement (Barrett Business Services Inc)

Attestation Form. As indicated above, I have elected to use shares of Pacific Financial Corporation CytoDyn common stock that I already own to pay the Aggregate Purchase Price of the Option (and withholding taxes, if applicable)Option. I attest to the ownership of the shares represented by the certificate(s) listed below or to the beneficial ownership of the shares held in the name of my broker, as indicated in the attached copy of my brokerage statement. I will be deemed to have delivered such shares to Pacific CytoDyn in connection with the exercise of my Option. I understand that, because I (and any joint owner) will retain ownership of the shares (the "Payment Shares") deemed delivered to pay the Aggregate Purchase Price (and withholding taxes, if applicable)Price, the number of shares to be issued to me upon exercise of my Option will be reduced by the number of Payment Shares. I represent that I have full power to deliver and convey certificates representing the Payment Shares to Pacific CytoDyn and by such delivery and conveyance could have caused Pacific CytoDyn to become sole owner of the Payment Shares. The joint owner of the Payment Shares, if any, by signing this Form, consents to these representations and to the exercise of the Option by this attestation. -10- ‌ O-_____ ​ ​ ​ I certify that the Payment Shares have not been used or acquired in a stock-for-stock exercise of any option within the six months preceding the exercise of this Option. I also certify that, if the Payment Shares were acquired by me upon exercise of a stock option or as restricted shares, (a) I have held the Payment Shares for at least six months, and (b) any Payment Shares originally issued to me as restricted shares are now fully vested. List certificate(s) and number of shares covered, or attach a copy of your brokerage statement: Common Stock Certificate Number Number of Shares Covered ​ ​ ​ ​ ​ ​ ​ Date: __________________ Print Name of Option Holder: Optionholder:​ ​​ ​​ ​​ ​​ ​​ ​​ ​ Signature of Option Holder: Optionholder:​ ​​ ​​ ​​ ​​ ​​ ​​ ​ Print Name of Joint Owner: Owner:​ ​​ ​​ ​​ ​​ ​​ ​​ ​ Signature of Joint Owner: Owner:​ ​​ ​​ ​​ ​​ ​​ ​​ ​ If you are attaching a copy of your brokerage statement, you must have your securities broker complete the following: The undersigned hereby certifies that the foregoing attestation is correct. ​ ​ ​​ ​​ ​​ ​​ ​​ Name of Brokerage Firm Date: By: Telephone No.: By:​ ​​ ​​ ​​ ​​ ​ ​ ​​ ​​ ​​ ​​ ​​ Print Name of Signing BrokerBroker Date:​ ​​ ​​ ​​ ​​ ​ Telephone No.:​ ​​ ​​ ​ -11- ‌ O-_____

Appears in 1 contract

Samples: Incentive Plan Stock Option Award Agreement (CytoDyn Inc.)

Attestation Form. As indicated above, I have elected to use shares of Pacific Financial Corporation CytoDyn common stock that I already own to pay the Aggregate Purchase Price of the Option (and withholding taxes, if applicable)Option. I attest to the ownership of the shares represented by the certificate(s) listed below or to the beneficial ownership of the shares held in the name of my broker, as indicated in the attached copy of my brokerage statement. I will be deemed to have delivered such shares to Pacific CytoDyn in connection with the exercise of my Option. I understand that, because I (and any joint owner) will retain ownership of the shares (the "Payment Shares") deemed delivered to pay the Aggregate Purchase Price (and withholding taxes, if applicable)Price, the number of shares to be issued to me upon exercise of my Option will be reduced by the number of Payment Shares. I represent that I have full power to deliver and convey certificates representing the Payment Shares to Pacific CytoDyn and by such delivery and conveyance could have caused Pacific CytoDyn to become sole owner of the Payment Shares. The joint owner of the Payment Shares, if any, by signing this Form, consents to these representations and to the exercise of the Option by this attestation. I certify that the Payment Shares have not been used or acquired in a stock-for-stock exercise of any option within the six months preceding the exercise of this Option. I also certify that, if the Payment Shares were acquired by me upon exercise of a stock option or as restricted shares, (a) I have held the Payment Shares for at least six months, and (b) any Payment Shares originally issued to me as restricted shares are now fully vested. ​ ​ ​ ​ List certificate(s) and number of shares covered, or attach a copy of your brokerage statement: Common Stock Certificate Number Number of Shares Covered ​ ​ ​ ​ ​ ​ ​ Date: __________________ Print Name of Option Holder: holder:​ ​​ ​​ ​​ ​​ ​​ ​​ ​ Signature of Option Holder: holder:​ ​​ ​​ ​​ ​​ ​​ ​​ ​ Print Name of Joint Owner: Owner:​ ​​ ​​ ​​ ​​ ​​ ​​ ​ Signature of Joint Owner: Owner:​ ​​ ​​ ​​ ​​ ​​ ​​ ​ If you are attaching a copy of your brokerage statement, you must have your securities broker complete the following: The undersigned hereby certifies that the foregoing attestation is correct. ​ ​ ​​ ​​ ​​ ​​ ​​ Name of Brokerage Firm Date: By: Telephone No.: By:​ ​​ ​​ ​​ ​​ ​ ​ ​​ ​​ ​​ ​​ ​​ Print Name of Signing BrokerBroker Date:​ ​​ ​​ ​​ ​​ ​ Telephone No.:​ ​​ ​​ ​

Appears in 1 contract

Samples: Stock Option Award Agreement (CytoDyn Inc.)

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Attestation Form. As indicated above, I have elected to use shares of Pacific Financial Corporation BBSI common stock that I already own to pay the Aggregate Purchase Price of the Option (and withholding taxes, if applicable). I attest to the ownership of the shares represented by the certificate(s) listed below or to the beneficial ownership of the shares held in the name of my broker, as indicated in the attached copy of my brokerage statement. I will be deemed to have delivered such shares to Pacific BBSI in connection with the exercise of my Option. I understand that, because I (and any joint owner) will retain ownership of the shares (the "Payment Shares") deemed delivered to pay the Aggregate Purchase Price (and withholding taxes, if applicable), the number of shares to be issued to me upon exercise of my Option will be reduced by the number of Payment Shares. I represent that I have full power to deliver and convey certificates representing the Payment Shares to Pacific BBSI and by such delivery and conveyance could have caused Pacific BBSI to become sole owner of the Payment Shares. The joint owner of the Payment Shares, if any, by signing this Form, consents to these representations and to the exercise of the Option by this attestation. I certify that the Payment Shares have not been used or acquired in a stock-for-stock exercise of any option within the six months preceding the exercise of this Option. I also certify that, if the Payment Shares were acquired by me upon exercise of a stock option or as restricted shares, (a) I have held the Payment Shares for at least six months, and (b) any Payment Shares originally issued to me as restricted shares are now fully vested. List certificate(s) and number of shares covered, or attach a copy of your brokerage statement: Common Stock Certificate Number Number of Shares Covered Date: Print Name of Option Holder: Signature of Option Holder: Print Name of Joint Owner: Signature of Joint Owner: If you are attaching a copy of your brokerage statement, you must have your securities broker complete the following: The undersigned hereby certifies that the foregoing attestation is correct. Name of Brokerage Firm Date: By: Telephone No.: Print Name of Signing Broker

Appears in 1 contract

Samples: Award Agreement (Barrett Business Services Inc)

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