ASSIGNMENT AND TRANSFER
OF STOCK CERTIFICATE
FOR VALUE RECEIVED, the undersigned hereby sells, assigns
and transfers to _, (_) shares of the stock of _ (Corporation)
standing in the name of the undersigned on the books of the
Corporation and represented by Certificate No. _.
The undersigned hereby and irrevocably constitutes and
appoints _, attorney-in-fact, to transfer the said stock on
the books of the within named Corporation with full power of
substitution in the premises.
In the presence of: