First
Name:
Last
Name:
Job
Title:
Company
Name:
Address:
City:
State:
[Choose One]
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington, D.C.
West Virginia
Wisconsin
Wyoming
Zip:
Phone:
FAX:
Your
E-Mail Address:
Company's Web
Address:
Industry:
Public
Corporation:
YES
NO
If yes, ticker symbol:
Sales
Range:
[Choose One]
Under $500,000
$500,000 to $2 Million
$2 Million to $10 Million
$10 Million to $50 Million
$50 Million to $100 Million
$100 Million to $250 Million
Over $250 Million
Number of
Employees:
[Choose One]
Less than 10
10 - 25
25 - 50
50 - 100
100 - 500
500 - 1,000
1,000 - 5,000
5,000 - 10,000
Over 10,000
Type of
Stock Option Project:
[Choose One]
Design and Installation
Administration
Valuations - Historical
Valuations - On-going
Other (Please explain in Comments section)
Then, answer the questions corresponding to your
selected Project Type(s), then push Submit.
Stock Option
Design and Installation:
(Push to skip )
If the Company is
Privately-Held:
1) Are there current and/or historical
valuations for the period in which your company requires grants to be
available?
YES NO
2) Is the company going public with in the next
12-months?
YES NO
If no, are
there future plans to go public?
YES
NO
Has it been determined how many
shares will be allocated to the Option Plan? YES
NO
If yes, is the company growing enough to support the
dilution the Option Shares will cause?
YES NO
NOT SURE
Has the type of Option Plan
been determined? YES
NO
If yes, which type:
[Choose One]
Incentive Stock Options (ISO)
Non-Qualified Stock Options (NQSO)
Combination ISO and NQSO
If no:
1) Will the Option Plan be used for management or for all employees? MGMT
EEs BOTH
2) Are there any non-employees that will be
granted Stock Options? YES
NO
Check here if you would like to
have the Option Plan presented to the employees/participants by FTSI
after Installation:
** After Installation is complete, Administration and Valuation services
may or may not be performed by FTSI and is at the discretion of the
Company. All Administration and Valuation Costs will be quoted separately.
(If you would like a quote for these additional services, answer the
question below corresponding to the services you require after
Installation.)
Stock Option
Administration
(Push to skip )
Check here if you would like a quote for
set-up
Administration:
(i.e.
initial grants after plan installation)
Check here if you would like a quote for
on-going
Administration:
Stock Option
Valuations - Historical:
(Push to skip )
How many historical years do
you need valuations for?
What is the frequency during each
of those historical years?
Select One:
Monthly
Quarterly
Annually
Other: Quantity per year:
Stock Option
Valuations - On-going:
(Push to skip )
How often would valuations be required?
Select One:
Monthly
Quarterly
Annually
Additional Comments: