The undersigned hereby acknowledges receipt of a photocopy of Certificate No. CS-Certificate No. for No. Purchased shares of Common Stock of Company Name, a Delaware corporation (the “Company”).
The undersigned further acknowledges that the Secretary of the Company, or his or her designee, is acting as escrow holder pursuant to the Common Stock Purchase Agreement that Purchaser has previously entered into with the Company. As escrow holder, the Secretary of the Company, or his or her designee, holds the original of the aforementioned certificate issued in the undersigned’s name.
Dated: Date this Document is Signed
Name: Purchaser Contact Name
Title: Purchaser Contact Title
Fax: Purchaser Fax
email: Purchaser Email
Spouse of Purchaser (if applicable)