ASSIGNMENT SEPARATE FROM CERTIFICATE
FOR VALUE RECEIVED and pursuant to that certain Restricted Stock Purchase Agreement between the undersigned (“Purchaser”) and Company Name, a Delaware corporation (the “Company”), dated Date (the “Agreement”), Purchaser Name hereby sells, assigns and transfers unto the Company Name (No. of shares) shares of the Common Stock of the Company, standing in Purchaser’s name on the books of the Company and represented by Certificate No. Certificate No., and hereby irrevocably constitutes and appoints Purchaser Name to transfer said stock on the books of the Company with full power of substitution in the premises. THIS ASSIGNMENT MAY ONLY BE USED AS AUTHORIZED BY THE AGREEMENT AND THE EXHIBITS THERETO.
Address: Purchaser Address
Spouse of Purchaser (if applicable)
Instructions: Please do not fill in any blanks other than the signature line. The purpose of this assignment is to enable the Company to exercise its repurchase option set forth in the Agreement without requiring additional signatures on the part of Purchaser.