Stock Option Exercise Notice Template

To: [Company Name]
Attention: [Stock Administration / Legal Department / Corporate Secretary]
Address: [Address]
Email: [Email Address]

From: [Option Holder Full Name]
Address: [Address]
Email: [Email Address]
Phone Number: [Phone Number]

Date: [Date]

Subject: Stock Option Exercise Notice

1. Option Holder Information

Option Holder Name: [Full Name]
Employee / Consultant / Director ID, if applicable: [ID Number]
Mailing Address: [Address]

2. Grant Information

I hold an option grant issued under the following plan or agreement:

Stock Option Plan Name: [Plan Name]
Option Agreement Date: [Date]
Grant Date: [Date]
Grant Number or Reference Number: [Number, if applicable]

3. Notice of Exercise

I hereby elect to exercise:

☐ all vested options available for exercise
☐ a portion of my vested options

Number of Option Shares Being Exercised: [Number]

4. Exercise Price

Exercise Price Per Share: [$Amount]

Total Exercise Price Due: [$Amount]

If applicable, additional withholding, taxes, or related amounts shall be handled according to the company’s applicable plan documents, agreements, and procedures.

5. Payment Method

Payment for the exercised option shares will be made as follows:

☐ cash
☐ check
☐ wire transfer
☐ payroll deduction, if permitted
☐ cashless exercise, if permitted
☐ net exercise, if permitted
☐ other: [Describe]

Additional payment details, if any:

[Insert details]

6. Share Issuance Instructions

Please issue the shares as follows:

☐ in my individual name
☐ jointly with: [Name]
☐ to the following account or transfer agent details: [Details]
☐ in uncertificated or electronic book-entry form
☐ other: [Describe]

7. Acknowledgments

I acknowledge and agree that:

the exercise is subject to the terms of the applicable stock option plan and option agreement;
the company may require additional documents, tax forms, or withholding amounts before issuing shares;
the company may delay issuance until all required conditions have been satisfied;
I have reviewed the applicable grant terms and understand the effect of this exercise notice.

8. Additional Notes

Additional comments or instructions, if any:

[Insert notes]

9. Signature

Option Holder Signature: __________________________
Name: [Full Name]
Date: [Date]

10. Company Acknowledgment

Received By: [Full Name]
Title: [Job Title]
Company Name: [Company Name]
Date Received: [Date]

Notes or Internal Processing Comments:

[Insert notes]