FairPoint Communications 2010 Annual Report Download - page 195

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EXHIBIT A
FAIRPOINT COMMUNICATIONS, INC.
PRE-CLEARANCE REQUEST FORM
To: FairPoint Communications, Inc. (the “Company”)
Insider Trading Compliance Officer
From:
Re: Proposed transaction in the Company’s Securities
This is to advise you that the undersigned intends to execute a transaction in the Company’s securities on ___________ ____, 20__, and does hereby request
that the Company pre-clear the transaction as required by the Company’s Insider Trading Policy (the “Policy”).
The general nature of the transaction is as follows (i.e. open market purchase of 10,000 shares of common stock through NASDAQ, privately negotiated sale
of warrants for the purchase of 5,000 shares of common stock, etc.):
The undersigned is not in possession of Material Nonpublic Information (as defined in the Insider Trading Policy) about the Company and will not enter into
the transaction if the undersigned comes into possession of Material Nonpublic Information about the Company between the date hereof and the proposed trade
execution date.
The undersigned has read and understands the Policy and certifies that the above proposed transaction will not violate the Policy.
The undersigned agrees to advise the Company promptly if, as a result of future developments, any of the foregoing information becomes inaccurate or
incomplete in any respect. The undersigned understands that the Company may require additional information about the transaction, and agrees to provide
such information upon request.
Dated: Very truly yours,
[Signature]
[Print Name]
Approved:
Insider Trading Compliance Officer
LEGAL_US_E # 88315277.2
Charlotte #25974 v3