FOR VALUABLE CONSIDERATION, the receipt of which is hereby acknowledged, the

undersigned hereby assigns, transfers, and conveys to [name of transferee] all of the right,
title, and interest of the undersigned in and to [number of shares of common stock] shares
of the common stock of [name of corporation], a corporation created under the laws of the
State of [name of state of incorporation] (the “Corporation”), represented by Certificate
Number [number] and hereby irrevocably appoints [name of attorney or stock transfer
agent] as attorney-in-fact to transfer the stock on the books of the Corporation with full
power of substitution in the premises.

Dated: [date of resolution]

_____________ [Name of transferor]