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

        Dated:                          _______________________________

       In the presence of:

                                                     Form 211


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