4008
EMPL. NO.
NAME - Print
(LAST)
(FIRST)
(INITIAL)
WAGE TYPE
PUBLIC SERVICE ENTERPRISE GROUP
EMPLOYEE STOCK PURCHASE PLAN — ENROLLMENT FORM
o
Initial Authorization
o Change Authorization
Deduct Weekly $______________.00.
(Max. 10% of Weekly Base Pay)
(Min. $5/Week)
o
I hereby withdraw from the PSEG Employee Stock Purchase Plan.
I wish to be a participant in the PSEG Employee Stock Purchase Plan (Plan) and authorize PSEG to withhold from my pay or sick benefits each pay
period the amount indicated above and to pay such amount and all dividends on shares of Enterprise Common Stock held for my account under the Plan to the
Independent Agent selected by PSEG.
I appoint the Independent Agent selected by PSEG to act as my Agent to use such payroll deductions and dividends to purchase shares of Common
Stock for my account under the Plan. I understand that PSEG may change the Independent Agent from time to time.
Certificates evidencing shares purchased under the Plan will be issued in the name of the participant only.
Under penalties of perjury, I certify that I am not subject to backup withholding.
Eligibility: Participation in the Plan is open to active employees, age 18 with one or more years of service.
o
I have been provided with a copy of the prospectus.
Employee Signature __________________________________________________________________________________________ Date ______________
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