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Exhibit 10.11.5
WESTERN STAFF SERVICES, INC.
INTERNATIONAL EMPLOYEE STOCK PURCHASE PLAN ("IESPP")
ENROLLMENT/CHANGE FORM
Action Complete Sections:
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| SECTION 1: | [_] New Enrollment 2, 3, 6, 7 AND sign attached
-------------- Stock Purchase Agreement
ACTIONS
[_] Payroll Deduction Change 2, 4, 7
[_] Terminate Payroll Deductions 2, 5, 7
[_] Beneficiary Change 2, 6, 7
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| SECTION 2: |
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Name ___________________________________________________________________
Last First MI Dept.
PERSONNEL
DATA
Home or Mailing Address ________________________________________________
Street
________________________________________________________________________
City State Zip Code
Social Security #: [_][_][_] - [_][_] - [_][_][_][_]
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| SECTION 3: |
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Effective with the Purchase Period Beginning: Payroll Deduction Amount: ______ % of cash earnings*
[_] February _, 199_
NEW [_] August _, 199_ * Must be a multiple of 1% up to a maximum of 10% of
ENROLLMENT cash earnings
[_] Initial Purchase Period -- November 3, 1996
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| SECTION 4: |
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PAYROLL Effective with the I authorize the following new level of payroll
DEDUCTION Pay Period Beginning: ____________________________ deduction: __% of cash earnings
CHANGE Month, Day and Year
* Must be a multiple of 1% up to a
maximum of 10% of cash earnings
NOTE: You may reduce your rate of payroll deductions once per purchase period to become effective as soon as possible
following the filing of the change form. You may also increase your rate of payroll deductions to become
effective as of the start date of the next purchase period.
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| SECTION 5: |
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Effective with the Your election to terminate your payroll deductions
TERMINATE Pay Period Beginning: ____________________________ for the balance of the purchase period cannot be changed,
PAYROLL Month, Day and Year and you may not rejoin the purchase period at a later
DEDUCTIONS date. You will not be able to resume participation in the
IESPP prior to the commencement of the next
purchase period.
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In connection with my voluntary termination of payroll deductions (or an approved leave of absence), I elect the
following action regarding my IESPP payroll deductions to date in the current purchase period:
[_] Purchase shares of Western Staff Services, Inc. at end of the period
OR
[_] Refund IESPP 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 IESPP, and your IESPP payroll deductions
collected in that purchase period will automatically be refunded to you.
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| SECTION 6: |
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Beneficiary(ies) Relationship of Beneficiary(ies)
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BENEFICIARY
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| SECTION 7: |
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AUTHORIZATION
I WOULD LIKE MY CERTIFICATE TO BE ISSUED AS FOLLOWS: (PRINT NAME(S) EXACTLY AS THEY SHOULD APPEAR.)
[_] My name only, ___________________________________________________.
[_] My name, ____________________________, and my spouse, _____________________________________________, [_] AS COMMUNITY
PROPERTY OR [_] AS JOINT TENANTS.
[_] Issued in street name and delivered to the Corporation-designated brokerage account maintained on my behalf.
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Date Signature of Employee
