ASSIGNMENT AND TRANSFER OF STOCK CERTIFICATE
FOR VALUE RECEIVED, the undersigned hereby sells, assigns and transfers to _, (_) shares of the stock of _ (Company) standing in the name of the undersigned on the books of the Company 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 Company with full power of substitution in the properties.
Dated: _
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In the presence of: