Assignment of Stock Form

For good and valuable consideration, receipt of which is hereby acknowledged, I, [Name] the undersigned, residing at [Address] hereby sell, assign and transfer to [Name], residing at [Address], [Number] shares of the stock of [Name of Corporation] (the "Corporation") standing in my name on the books of the Corporation, represented by Certificate No. [Certificate Number], and hereby irrevocably constitute and appoint [Name], attorney-in-fact to transfer the stock on the books of the within named Corporation, with full power of substitution in the premises.

Dated: [Month, Day, Year]

In the presence of:

Signature of Witness