FOR VALUABLE CONSIDERATION, the receipt of which is hereby acknowledged, [SELLER'S NAME] ("Seller") hereby assigns, transfers, and conveys to [BUYER'S NAME], all of Seller's right, title, and interest in and to [NUMBER] common shares of [CORPORATION'S NAME], a [STATE] corporation, represented by Certificate No. [NUMBER] and hereby irrevocably appoints [NAME] as Seller's attorney-in-fact to transfer said shares on the books of [CORPORATION'S NAME] with full power of substitution in the premises.

Date:

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[SELLER'S NAME AND, IF APPLICABLE,

TITLE]