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EXHIBIT 99.12
COLLATERAL THERAPEUTICS, INC.
EMPLOYEE STOCK PURCHASE PLAN ("ESPP")
ENROLLMENT/CHANGE FORM
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Action Complete Sections
Section 1: | | New Enrollment 2, 3, 7 and sign Stock Purchase
Agreement
Actions | | Payroll Deduction Change 2, 4, 7
| | Terminate Payroll Deductions 2, 5, 7
| | Leave of Absence 2, 6, 7
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SECTION 2:
PERSONNEL DATA
Name:
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Last First MI Dept.
Home Address:
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Street
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City State Zip Code
Social Security #:
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Section 3:
NEW ENROLLMENT Interval Beginning: Payroll Deduction Amount: ___% of base
salary*
| | August 1, 2000
| | February 1, 2001 * Must be a multiple of 1% up to a
| | August 1, 2001 maximum of 10% of base salary
| | February 1, 2002
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SECTION 4: Effective with the payroll Pay Period I authorize the following new level of
beginning: deduction: ___% of base salary*
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Month, Day and Year * Must be a multiple of 1% up to a
maximum of 10% of base salary
PAYROLL DEDUCTION CHANGE
NOTE: You may reduce your rate of payroll
deductions once per 6-month purchase interval
to become effective as soon as possible
following the filing of the change form. You
may increase your rate of payroll deductions
to become effective as of the start date of
the next 6-month purchase interval (February
1 or August 1).
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SECTION 5: Effective with the payroll Pay Period Your election to terminate your payroll
beginning: deductions for the balance of the
offering period cannot be changed, and
------------------------------ you may not rejoin the offering period
Month, Day and Year at a later date. You will not be able
to resume participation in the ESPP
until the start of the next offering
period.
In connection with my voluntary termination
of payroll deductions, I elect the following
action regarding my ESPP payroll deductions
to date in the current purchase interval:
| | Purchase shares of Collateral Therapeutics, 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 ABSENCE
|_| Purchase shares of Collateral Therapeutics, Inc. on next 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.
SECTION 7:
AUTHORIZATION
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Date Signature of Employee
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