[Date]

[Address]


FOR VALUE RECEIVED, the undersigned hereby sells, assigns 
and transfers to [Name of  Recipient], [#] shares of the stock of 
[Name 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 
[Name of Transfer Agent], attorney-in-fact, to transfer the said stock on  
the books of the within named Corporation with full power of 
substitution on the premises. 

Signed under seal this [date] day of [month, year]. 


________________________________________
(clearly print name after signature)


Dated: 

Witness: ______________________________
               [clearly print name after signature]


Sworn and subscribed before me this [numerical] day of [Month], 
[Year] A.D.
   

Notary Public: ______________________________
                           [clearly print name after signature]

My Commission expires: [Date]