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.

Dated: _

_______________________________
[Signature]

In the presence of:

_______________________________
[Signature]