ASSIGNMENT AND TRANSFER OF STOCK CERTIFICATE
FOR VALUE RECEIVED, the undersigned hereby sells, assigns and transfers to [NAME OF
ASSIGNEE] the following shares of the stock of [NAME OF COMPANY ON STOCK CERTIFICATE]
(the "Corporation") standing in the name of the undersigned on the books of the Corporation and
represented by the following Certificate No(s).:
Certificate No. Number and Class of Shares
The undersigned hereby and irrevocably constitutes and appoints [NAME OF ATTORNEY] as his/her/its
attorney to transfer the said stock on the books of the Corporation with full power of substitution in the
Dated this [number] day of [month], [year].
IN WITNESS WHEREOF, this Assignment and Transfer is executed on the date first above written.
Assignor Name of Assignor
SIGNED, SEALED AND DELIVERED in the pr