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P.O. Box 407193 # Fort Lauderdale, Florida 33340
(954) 581-9993 office # (954) 316-9201 fax

 
____________ (Date)

 
 
 
Dear :

 

  Granted To:          
Grant Date:
          Quantity Granted:           
Option Price:                                                        
$___ per share        
Expiration:
          Vest Schedule: __% per year         Type (ISO or NQ):   

 
By my signature below, I hereby acknowledge receipt of this Option granted on
the date shown above, which has been issued to me under the terms and conditions
of the 21st Century Holding Company 2002 Stock Option Plan (the "Plan"). I
further acknowledge receipt of the copy of the Plan and agree to conform to all
of the terms and conditions of the Option and the Plan.
 

     
Signature
 
Date

       
Note: If there are any discrepancies in the name or address shown above, please
make the appropriate corrections on this form.