Stock Power Form

The undersigned hereby assigns and transfers to the National Foundation for Infectious Diseases:

Shares of Stock

______ shares of the common stock of ___________________ represented by Certificate No.(s) ____________________ inclusive, standing in the name of the undersigned on the books of said Corporation.

or

Bond

_______ bond of ______________________________ in the principal amount of $______, Certificate No._______ standing in the name of the undersigned on the books of said Corporation.

The undersigned does (do) hereby irrevocably constitute and appoint _______________ Attorney to transfer the said stock(s), bond(s), or debenture(s), as the case may be, on the books of said Corporation with full power of substitution in the premises.

Signed ___________________________ Date _______________
Donor

Signed ___________________________ Date _______________
Donor (joint-owner)

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