Employee Stock Ownership Plan

EMPLOYEE STOCK OWNERSHIP PLAN - PARTICIPANT ENROLLMENT AND ELECTION

Plan Name:    Employer (Plan Sponsor):

Participant Personal Information

Position and Employment Information

Enrollment and Participation Election

By submitting this form I elect to become a Participant under the Employer's Employee Stock Ownership Plan (Plan) and understand that my participation will be governed by the Plan document, the trust agreement, and applicable law. I elect to:

Participate in the Plan and receive allocations of Employer stock and/or cash contributions as provided by the Plan.

Allocation percentage of eligible compensation to be credited to my participant account (if applicable):    Fixed contribution amount (if plan permits):

Election effective date (first payroll effective for contributions and allocations):

Vesting and Account Treatment

I acknowledge that contributions allocated to my participant account are subject to the Plan's vesting schedule and any applicable forfeiture provisions. I select the acknowledged vesting schedule as follows (select one):

Graded vesting: 20% per year over five (5) years as described in the Plan.

Cliff vesting: 100% after three (3) years of service as described in the Plan.

Beneficiary Designation

Primary Beneficiary (receives benefits on Participant's death)

Contingent Beneficiary

Distribution Elections

In the event of a distributable event I elect (select one):

Lump sum distribution (subject to Plan provisions and tax withholding).

Installments over years (subject to Plan administrator approval).

Direct rollover to a qualified retirement account. Receiving institution name:

Loans and Withdrawals

The Plan may permit Participant loans or in-service withdrawals in accordance with Plan rules. I request the Plan Administrator consider my eligibility for a loan (if applicable):

Employment History (most recent first)

Education

Professional References (3)

Legal Disclosures and Acknowledgements

At-Will Employment: I acknowledge that my employment is at-will unless a written agreement signed by an authorized employer representative provides otherwise. Nothing in this Plan enrollment or participation form alters the at-will relationship except by a signed written agreement.

Equal Opportunity: The Employer is an equal opportunity employer. Participation in the Plan, eligibility, and allocations shall be applied without discrimination except as permitted by the Plan document and applicable law.

Background Checks and Employment Verification: I authorize the Employer and its agents to contact former employers and listed references, and to obtain or verify information relevant to my employment and participation in the Plan, including criminal, employment and educational records where permitted by law. I further authorize release of such information to the Plan Administrator and Plan Trustee as required for Plan administration.

Participant Certification and Consent

I certify that all information provided in this form is true and complete to the best of my knowledge. I understand and agree that:

• I have received or will receive a copy of the Plan summary and have had an opportunity to review the Plan terms governing eligibility, allocations, vesting, loans, withdrawals and distributions.
• I consent to the collection and use of my personal information for Plan administration and to the release of information to the Plan Trustee, third-party administrators, and government agencies as required by law.
• I acknowledge potential tax consequences of contributions and distributions and accept responsibility for any tax reporting and withholding required by law.
• I understand that the Plan Administrator has discretionary authority to interpret Plan provisions and resolve ambiguities in accordance with the Plan document and applicable law.

Authorization: I hereby authorize payroll deduction or Employer contribution as applicable for Plan participation and acknowledge that allocations of stock or cash are subject to the terms and conditions of the Plan document and trust agreement.

I certify that the information provided is true and complete, and I accept the terms above.

Plan Administrative Provisions (Summary of Key Legal Terms)

Definitions: Capitalized terms used herein have the meanings set forth in the Plan document. Eligibility and participation rights are determined under the Plan document and the trust agreement.

Contributions and Allocations: Employer contributions will be made in the form described in the Plan (stock and/or cash). Allocations to participant accounts will be made in accordance with the allocation formula set forth in the Plan.

Vesting and Forfeitures: Vesting shall be determined by the vesting schedule established by the Plan. Forfeitures will be handled and applied in the manner prescribed by the Plan document.

Distributions: Distributions will be made upon a distributable event as defined in the Plan. Election of form and timing of distributions is subject to Plan rules and administrator approval.

Amendment and Termination: The Employer reserves the right to amend or terminate the Plan subject to the terms of the Plan document and applicable law. No amendment or termination shall deprive a Participant of any nonforfeitable interest in accordance with the Plan.

Governing Law and Dispute Resolution: The Plan is subject to applicable federal and state law. Any disputes arising under the Plan shall be resolved in accordance with the dispute resolution procedures set forth in the Plan document.

Authorization to Contact, Background Checks and Data Use

I authorize the Employer and its authorized agents to contact references and prior employers provided on this form for purposes of verifying employment history, education, and other information relevant to employment and Plan participation. I consent to background checks where permitted by law and understand that information obtained may be used in Plan administration.

I further acknowledge that the Employer may maintain electronic records and that my submission of this form constitutes consent to electronic transmission and storage of Plan-related documents.

Participant Notices

Tax Withholding and Reporting: Distributions and certain transactions may result in tax withholding and reporting. The Participant acknowledges responsibility for reviewing tax consequences and consulting with a tax advisor if desired.

Receipt of Plan Documents: By signing below, I acknowledge that I have been given or will be provided a copy of the Plan summary and understand my rights and obligations as a Participant under the Plan.

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