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: _

_______________________________

In the presence of: