Stock Power Form - Worldwide Stock Transfer printable pdf download

Stock Power Form - Worldwide Stock Transfer

Stock Power Form

*All certificates to be transferred must be enclosed with this stock power form.

*The signature to this assignment must correspond with the name as written upon the face of the certificate in every

particular without alteration or enlargement or any change whatsoever. The signature of the person executing this

power must be guaranteed by an eligible Guarantor Institution such as a Commercial Bank, Trust Company, Securities

Broker/Dealer, Credit Union, or Savings Association participating in a Guarantee Medallion Program approved by the

Securities Transfer Association, Inc and Pursuant to S.E.C Rule 17Ad-15.

For value received I/we hereby sell, assign and transfer unto:

1. Print Name of Transferee/New Owner: ___________________________________________________________

2. New Owners Address: ________________________________________________________________________

3. Tax ID Number: _______________________________________________________________________________

4. Number of Shares and/or dividend reinvestment shares of the common stock of: ___________________________

5. Name of Company: ___________________________________________________________________________

6. Currently Registered as: ________________________________________________________________________

7. Represented by Certificate Number(s): ___________________________________________________________

8. Today’s Date: ______________________________________________________________________________

9. Print Name of Person(s) Transferring Shares: ______________________________________________________

I the undersigned does hereby irrevocably constitute and appoint: WORLDWIDE STOCK TRANSFER, LLC

to transfer the said stock on the books of the said company with full power of substitution in the premises.

10. Signature of Person(s) Transferring Shares: ______________________________________________________

Affix Medallion Guaranty Stamp

Stock Power Form - Worldwide Stock Transfer