For value received, I, ______________________, of _____________________, assign to _______________, of __________________, assignee ____ shares of stock of_____________________, which shares stand in my name on the books of such corporation and are represented by certificate No. ______.

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 _____________ with full power of substitution in the premises.

Dated ____________________, 19___.

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