GLOBECOMM SYSTEMS, INC.
EMPLOYEE STOCK PURCHASE PLAN ("ESPP")
ENROLLMENT/CHANGE FORM
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SECTION 1: Action Complete Sections:
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ACTIONS [ ] New Enrollment 2, 3, 6, 7 and sign
attached Stock
Purchase Agreement
[ ] Payroll Deduction Change 2, 4, 7
[ ] Terminate Payroll Deductions 2, 5, 7
[ ] Beneficiary Change 2, 6, 7
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SECTION 2: Name
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Last First MI Dept.
PERSONNEL
DATA Home 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 Payroll Deduction
- ------------------ Interval Beginning: Amount: ____% of base
salary
NEW [ ] January 1,
ENROLLMENT [ ] July 1, * Must be a multiple of
1% up to a maximum of
10% of base salary
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SECTION 4: Effective with the
- ------------------ Pay Period Beginning:
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PAYROLL DEDUCTION
CHANGE
I authorize the following new level of
payroll deduction: ____% of base salary*
* Must be a multiple of 1% up to a maximum of 10% of
base salary
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.
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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 cannot be changed, and
you may not rejoin the purchase period at a later date.
You will not be able to resume participation in the ESPP
prior to the commencement of the next offering period.
In connection with my voluntary termination of payroll
deductions (or an approved leave of absence), I elect the
following action regarding my ESPP payroll deductions to
date in the current purchase interval:
[ ] Purchase shares of Globecomm Systems 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 leave of absence, I elect the
- ------------------ following action with respect to my ESPP payroll
deductions to date:
LEAVE OF [ ] Purchase shares of Globecomm Systems Inc. on next
ABSENCE scheduled purchase date
OR
[ ] Refund ESPP payroll deductions collected
NOTE: If you take an unpaid leave of absence, your
payroll deductions will immediately cease. If you return
to active status within 90 days after the start of your
leave, your payroll deductions will at that time
automatically resume at the rate in effect for you when
your leave began.
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SECTION 7:
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AUTHORIZATION I HEREBY AUTHORIZE THE SPECIFIC ACTION OR ACTIONS
INDICATED ABOVE.
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Date Signature of Employee