For value received, I, ________(1)______________, of __________(2)___________, assign to ________(3)_______, of ________(4)__________, assignee __(5)__ shares of stock of __________(6)___________, which shares stand in my name on the books of such corporation and are represented by certificate No. ___(7)___.

I warrant that the assigned certificate is genuine and, to my knowledge, valid, and that I have the legal right to transfer it.

I appoint assignee my attorney in fact to effect a transfer of the assigned shares on the books of _____(8)________ with full power of substitution in the premises.

Dated _________(9)___________, 19__(10)_.

_____________(11)_____________

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