ASSIGNMENT AND TRANSFER OF STOCK
CERTIFICATE
FOR VALUE RECEIVED, the undersigned
hereby sells, assigns and transfers to [r-Name] [r-NumberShares] shares of the
stock of [s-Company] (the “Corporation”) standing in the name of the
undersigned on the books of the Corporation and represented by Certificate No.
[s-CertificateNumber].
The undersigned hereby and
irrevocably constitutes and appoints [s-Attorney], attorney-in-fact, to
transfer the said stock on the books of the within named Corporation with full
power of substitution in the premises.
Dated: [l-Date]
CORPORATION TRANSFEROR
______________________________________ ___________________________________________
Signature Signature
______________________________________ ___________________________________________
[r-Name] [s-Name]
[r-Title] [s-Title]
In the presence of:
______________________________________
Signature
______________________________________
[s-Witness]
[s-WitnessTitle]
[s-WitnessCompany]
