FOR VALUE RECEIVED, the undersigned hereby sells , assigns and transfers to ____________ ,____________(number) 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: _______________________________

In the presence of:

_______________________________