EX-99.(A).(1).(III) 4 dex99a1iii.htm FORM OF ELECTION FORM FOR PARTICIPATION IN THE EXCHANGE OFFER Form of Election Form for participation in the Exchange Offer

Exhibit - (a)(1)(iii)

STEREOTAXIS, INC.

STOCK OPTION / STOCK APPRECIATION RIGHT EXCHANGE PROGRAM

PARTICIPANT ELECTION FORM

Please make an election on each individual grant of options or stock appreciation rights (“SARs”) by checking the appropriate box in the right hand column, sign and date the form and return to Sarah Kamp by 11:59 p.m. local St. Louis time on September 14, 2009 (subject to extension by the Company in its election).

For full instructions and disclosure concerning the Exchange Program, read the Offer to Exchange Certain Stock Options and Certain Stock Appreciation Rights referred to herein as the “Exchange Offer”.

 

    Outstanding Option Award Detail   Replacement Options Tender Offer Detail    

Employee
Name

   Grant
Date		   Strike
Price		   # of
Options		   Date Fully
Vested		   Expiration
Date		   Term
Remaining		   Strike
Price 1		   Eligibility   Exchange
Ratio		   Options
Received		   Date Fully
Vested 2		   Expiration
Date 3		   Term
Remaining 3		    
                           

 

¨ I do
elect to
exchange
this
option

 

¨ I do
not elect
to
exchange
this
option

    Outstanding Option Award Detail   Replacement Options Tender Offer Detail    

Employee
Name

   Grant
Date		   Strike
Price		   # of
Options		   Date Fully
Vested		   Expiration
Date		   Term
Remaining		   Strike
Price 1		   Eligibility   Exchange
Ratio		   Options
Received		   Date Fully
Vested 2		   Expiration
Date 2		   Term
Remaining 2		    
                           

 

¨ I do
elect to
exchange
this
option

 

¨ I do
not elect
to
exchange
this
option

 

1 The actual strike price of the Replacement Awards will be equal to the closing price on the last day of the offer period. The strike prices provided in this election form are estimated solely for the purpose of illustrating the exchange ratio which will be applicable given a particular strike price. See the Exchange Offer for more information.

 

2 Options received as part of the tender offer will have a minimum vesting period of one year or the current vesting schedule. See the Exchange Offer for more information.

 

3 Options received as part of the tender offer will have a minimum expiration date/term remaining that is one year and two weeks from the closing date of the tender offer. See the Exchange Offer for more information.

 

¨ Check here if this form is intended to replace previously submitted election form(s). By checking this box, the undersigned agrees that this election reform replaces and supersedes all previous election forms submitted by the undersigned.

Signed                            

Dated