MELLON INVESTOR SERVICES
STOCK POWER FORM
FOR VALUE RECEIVED, I/WE HEREBY
SELL, ASSIGN AND TRANSFER TO (1): _____________________________________________
SOCIAL SECURITY # OR TAX I.D. # OF NEW OWNER.
(2)_____________________________________________________________________________
PRINT/TYPE ALL NAMES & ADDRESS OF NEW OWNERS, INDICATE IF JOINT, TRUST OR
CUSTODIAN ACCOUNT
_____________________________________________________________________________
_____________________________________________________________________________
City State Zip Code
TRANSFER (3) _______________________ CERTIFICATE SHARES REPRESENTED BY THE
ENCLOSED CERTIFICATE NUMBER(S) (4) _____________________________, AND/OR
(5)__________________ BOOK-ENTRY SHARES (INCLUDING SHARES HELD FOR YOU IN A
DIVIDEND REINVESTMENT OR OTHER PLAN).
REGISTERED TO (6) ______________________________________________________________
ACCOUNT NUMBER (7) _____________________________________________________________
THE UNDERSIGNED DOES (DO) HEREBY IRREVOCABLY CONSTITUTE AND APPOINT MELLON
INVESTOR SERVICES ATTORNEY TO TRANSFER THE SAID STOCK ON THE BOOKS OF
_______________________________ WITH FULL POWER OF SUBSTITUTION IN THE PREMISES.
Company Name
SIGNATURE(S) OF REGISTERED OWNERS: Please sign as name appears on registration.
Joint owners should each sign. When signing as attorney, executor,
administrator, trustee or guardian, please give full title of such.
(8)__________________________________ Date:________________________________
Signature of registered holder
or authorized representative:
__________________________________ Telephone:___________________________
Signature of Joint Owner Daytime number
AFFIX MEDALLION SIGNATURE GUARANTEE by a financial institution enrolled in an
approved Medallion Program pursuant to S.E.C. Rule 17Ad-15.
---------------------------------------
| |
| |
| |
| |
| |
| |
| |
---------------------------------------
PDX/112816/141153/DLH/1423623.1
