Document:

exv10w6w1

EXHIBIT 10.6.1

IMPAX LABORATORIES, INC.

STOCK OPTION GRANT

	 	 	 	 	 
	Optionee Name:
	 	{FirstName}       {LastName}	 	 
	 	 	 

	 	 
	Address:
	 	 	 	 
	 	 	 

	 	 
	 	 	 	 	 
	 	 	 

	 	 
	 	 	 	 	 
	 	 	 

	 	 
	 
	Total Option Shares:	 	{Grant}	 
	 	 	 

	 	 
	 
	Exercise Price Per Share:	 	 	 
	 	 	 

	 	 
	 
	Date of Grant:	 	 	 
	 	 	 

	 	 
	 
	Expiration Date:	 	 	 
	 	 	 

	 	 

	 	 	 
	Type of Option:
	 	o Incentive Stock Option
	 	 	o Nonstatutory Stock Option

1. GRANT OF OPTION — Impax Laboratories, Inc. (the “Company”), hereby grants to Optionee named
above (“Optionee”) and Optionee hereby accepts a nontransferable option to purchase the total
number of shares of common stock of the Company set forth above (the “Shares”) at the exercise
price per share set forth above (the “Exercise Price”), subject to all of the terms and conditions
of this Stock Option Grant (this “Option”) and the Company’s 2002 Equity Incentive Plan (the
“Plan”). Optionee acknowledges receipt of a copy of the Plan, which is attached hereto as Exhibit
A. Optionee represents that he or she is familiar with the terms and conditions of the Plan and
hereby accepts this Option subject to all of the terms and conditions hereof and thereof. Optionee
hereby agrees to accept as binding, conclusive, and final, all decisions and interpretations of the
Board, or Committee, if applicable, (hereinafter the “Board”), as to any questions or disputes
arising under the Plan or this Option.

If designated as an Incentive Stock Option above, this Option is intended to qualify as an
“incentive stock option” (“ISO”) within the meaning of
Section 422 of the Code. Unless otherwise defined herein, capitalized terms used herein shall have
the meanings ascribed to them in the Plan.

 

 

2. RIGHT TO EXERCISE — During Optionee’s continued service with the Company or any Parent or
Subsidiary of the Company (or, in the case of a Nonstatutory Stock Option, an Affiliate of the
Company), this Option shall become exercisable over four years in 25% equal annual installments
from the date of the grant. Subject to earlier termination as provided in Section 5 below, to the
extent that this Option has become exercisable with respect to the Shares covered thereby, this
Option may thereafter be exercised by Optionee, in whole or in part, at any time or from time to
time prior to the Expiration Date.

3. RESTRICTION ON EXERCISE — This Option may not be exercised unless such exercise is in compliance
with the Securities Act, the Exchange Act, regulations promulgated thereunder and all applicable
state securities laws as they are in effect on the date of exercise, and the requirements of any
stock exchange or national market system on which the Company’s common stock may be listed at the
time of exercise. Optionee understands that the Company is under no obligation to register, qualify
or list the Shares with the Securities and Exchange Commission (“SEC”), any state securities
commission, or any stock exchange to effect such compliance.

4. TERMINATION OF SERVICE — Except as provided below in this Section, this Option shall terminate
and may not be exercised if Optionee’s continuous service with the Company or any Parent or
Subsidiary of the Company or, in the case of a Nonstatutory Stock Option, an Affiliate of the
Company (hereinafter “Continuous Service”) is terminated for any reason whatsoever. The Board shall
have discretion to determine whether Optionee’s Continuous Service with the Company or any Parent,
Subsidiary of Affiliate of the Company has terminated and the effective date on which such
termination occurred (the “Termination Date”).

     4.1. Death/Disability — If Optionee’s Continuous Service is terminated due to Death or Disability,
that portion of this Option which is exercisable on the Termination Date shall remain exercisable
until the earlier of the Expiration Date or the first anniversary of the Termination Date and, to
the extent not exercised during such period, shall thereupon terminate.

     4.2. Other Termination — If Optionee’s Continuous Service terminates for any reason other than
Death, Disability, or Cause, that portion of this Option which is exercisable on the Termination
Date shall remain exercisable until the earlier of the Expiration Date or the end of the
_______ (___) day period commencing on the Termination Date and, to the extent not exercised during such
period, shall thereupon terminate.

     4.3. Cause — Notwithstanding anything herein to the contrary, if Optionee’s Continuous Service is
terminated for Cause (or at a time when grounds for a termination for Cause exist), this Option
shall terminate in its entirety as of the Termination Date.

5. MANNER OF EXERCISE

     5.1. Exercise — To the extent exercisable under the provisions of the Option, this Option may be
exercised by delivery to the Company of an executed written notice of exercise to the Company’s
Secretary stating the number of full Shares with respect to which it is being exercised, and
accompanied by payment of the Exercise Price for the number of Shares being purchased, together
with payment of the amount, if any, required by the Company to satisfy its tax withholding
obligations resulting from such exercise.

Page 2

 

     5.2. Exercise Price — Payment for the Shares may be made in cash (by check) or, where approved by
the Board in its sole discretion and where permitted by law: (a) by cancellation of indebtedness of
the Company to Optionee; (b) by surrender of shares of common stock of the Company having a Fair
Market Value equal to the exercise price of the Option that have been owned by Optionee for more
than one (1) year (and which have been paid for within the meaning of SEC Rule 144 and, if such
Shares were purchased from the Company by use of a promissory note, such note has been fully paid
with respect to such shares), or were obtained by Optionee in the open public market; (c) by waiver
of compensation due or accrued to Optionee for services rendered; (d) provided that a public market
for the Company’s stock exists, through a “same day sale” commitment from Optionee and a
broker-dealer that is a member of the National Association of Securities Dealers (an “NASD Dealer”)
whereby Optionee irrevocably elects to exercise the Option and to sell a portion of the Shares so
purchased to pay for the Exercise Price and whereby the NASD Dealer irrevocably commits upon
receipt of such Shares to forward the Exercise Price directly to the Company; (e) provided that a
public market for the Company’s stock exists, through a “margin” commitment from Optionee and an
NASD Dealer whereby Optionee irrevocable elects to exercise the Option and to pledge the Shares so
purchased to the NASD Dealer in a margin account as security for a loan from the NASD Dealer in the
amount of the Exercise Price, and whereby the NASD Dealer irrevocably commits upon receipt of such
Shares to forward the Exercise Price directly to the Company (without any obligation or liability
on the part of the Company); or (f) by any combination of the foregoing.

     5.3. Withholding Taxes

          5.3.1. — Optionee hereby authorizes the Company to withhold from payroll and any other amounts
payable to Optionee, and Optionee otherwise agrees to make adequate provision for (including by
means of a cashless exercise to the extent permitted by the Company), any sums required to satisfy
the federal, state, local, foreign, and any other tax withholding obligations of the Company or an
Affiliate, if any, which arise in connection with the Option.

          5.3.2. — Upon Optionee’s request, subject to compliance with any applicable conditions or
restrictions of law, the Company may (but shall be under no obligation to) withhold from Shares
otherwise issuable to Optionee upon the exercise of this Option, a number of whole shares having a
Fair Market Value, determined by the Company as of the date of exercise, not in excess of the
minimum amount of tax required to be withheld by law.

          5.3.3. — If this Option is an Incentive Stock Option, by exercising this Option, Optionee agrees
that he or she will notify the Company in writing within fifteen (15) days after the date of any
disposition of any of the Shares that occurs within two (2) years after the date of this Option
grant or within one (1) year after Shares are transferred upon exercise of this Option, and will
otherwise provide the Company with such other information as the Company shall reasonably request.

     5.4 Issuance of Shares/Stockholder Rights — Provided that such notice and payment are in form and
substance satisfactory to the Company and counsel for the Company, the Company shall cause the
Shares to be issued in the name of Optionee or Optionee’s legal representative. Neither Optionee
nor any person entitled to exercise Optionee’s rights in the event of death will have any of the
rights of a stockholder with respect to the Shares, except to the extent that certificates for such
Shares shall have been issued upon the exercise of this Option.

Page 3

 

6. NONTRANSFERABILITY OF OPTION — The Option may not be transferred in any manner other than by
will or by the law of descent and distribution and may be exercised during the lifetime of Optionee
only by Optionee.

7. INDEPENDENT TAX ADVICE — Optionee agrees that Optionee has or will obtain the advice of
independent tax counsel regarding the federal and state income tax consequences of the receipt and
exercise of this Option and of the disposition of Common Stock acquired upon exercise hereof,
including advice regarding the imposition of the alternative minimum tax on tax preferences
generated by exercise of stock options and regarding any holding period requirements for
preferential tax treatment. OPTIONEE ACKNOWLEDGES THAT HE OR SHE HAS NOT RELIED AND WILL NOT RELY
UPON ANY ADVICE OR REPRESENTATIONS BY THE COMPANY OR BY ITS EMPLOYEES OR REPRESENTATIVES WITH
RESPECT TO THE TAX TREATMENT OF THIS OPTION OR ANY SHARES ISSUED PURSUANT HERETO.

8. NO
RIGHT TO CONTINUE AS EMPLOYEE — Nothing contained in this Option
shall:

(i) confer upon the Optionee any right to continue as an Employee, Officer, Director or Consultant
of the Company or of any Affiliate; or (ii) limit in any way the right of the Company or of any
Affiliate to terminate the Optionee’s position as an employee at any time.

9. BOARD DETERMINATIONS — Optionee hereby agrees to accept as binding, conclusive, and final all
decisions and interpretations of the Board (including any committee thereof), or other
administrator of the Plan, as to any questions arising under the Plan or this Option. This Option,
as supplemented by the Plan, shall bind and inure to the benefit of the Company and its successors
and assigns, and the Optionee and the Optionee’s estate in the event of death.

10. ENTIRE AGREEMENT — The Plan is incorporated herein by this reference. The Option and the Plan
constitute the entire agreement of the parties hereto and supersede all prior undertakings and
agreements with respect to the subject matter hereof.

	 	 	 	 	 	 	 
	COMPANY:

	 	IMPAX LABORATORIES,
INC.
	 	 
	 
	 	 	 	 	 	 
	 

	 	By:	 	 	 	 
	 

	 	 	 	 

	 	 

	 	 	 	 	 	 	 
	OPTIONEE: 	 	(Signature)

	 	 

Page 4exv10w6w2

EXHIBIT 10.6.2

IMPAX LABORATORIES, INC.

STOCK BONUS AWARD AGREEMENT

     An Award of Restricted Stock is hereby awarded on                     , ___ (the “Award Date”) by
Impax Laboratories, Inc. (the “Company”), to                      (the “Grantee”), in accordance
with the following terms and conditions, and the conditions contained in the Company’s Amended and
Restated 2002 Equity Incentive Plan (the “Plan”):

     1. Share Award. The Company hereby awards the Grantee                      shares (the
“Shares”) of Common Stock, par value $0.01 per share (“Common Stock”), of the Company pursuant to
the Plan, as the same may from time to time be amended, and upon the terms and conditions and
subject to the restrictions therein and hereinafter set forth (the “Award”). A copy of the Plan as
currently in effect is incorporated herein by reference and is attached hereto.

     2. Restrictions on Transfer and Restricted Period. During the period (the “Restricted
Period”) commencing on the Award Date and terminating on the dates ownership of the Shares vests as
provided below, the rights to the Shares and the Shares may not be sold, assigned, transferred,
pledged, or otherwise encumbered by the Grantee, except as hereinafter provided.

     During Grantee’s continued service with the Company or any of its Affiliates, ownership of the
Shares by Grantee shall vest in four equal annual installments of 25% on each anniversary of the
Award Date.

     Subject to the restrictions set forth in the Plan, the Board of Directors shall have the
authority, in its discretion, to accelerate the time at which any or all of the restrictions shall
lapse with respect to any Shares thereto, or to remove any or all of such restriction, whenever the
Board of Directors may determine that such action is appropriate by reason of changes in applicable
tax or other laws, or other changes in circumstances occurring after the commencement of the
Restricted Period. Ownership of all Shares will vest upon the Grantee’s death or disability.

     3. Termination of Service. Except as provided in Section 8 below, if the Grantee
ceases to maintain continuous service with the Company or any of its Affiliates (as defined in the
Plan) (“Continuous Service”) for any reason other than death or disability, all rights to Shares
which at the time of such termination of Continuous Service are subject to the restrictions imposed
by Section 2 above shall upon such termination of Continuous Service be forfeited to the Company.
Grantee’s service shall not be deemed to have terminated if he or she is transferred from the
Company to one of its Affiliates, or vice versa, or from one of the Company’s Affiliates to another
one of the Company’s Affiliates.

     4. Certificates for the Shares. The Company shall issue a certificate (or
certificates) in the name of the Grantee with respect to the Shares, and shall hold such
certificate (or certificates) on deposit for the account of the Grantee until the expiration of the
Restricted Period with respect to the Shares represented thereby.

 

 

     The Grantee further agrees that simultaneously with the execution of the Agreement, the
Grantee shall execute stock powers in favor of the Company, in the form attached hereto as
Attachment A, with respect to the Shares and that the Grantee shall promptly deliver such
stock powers to the Company.

     The following two paragraphs shall be applicable if, on the Award Date, the Common Stock
subject to such Award has not been registered under the Securities Act and under applicable state
securities laws, and shall continue to be applicable for so long as such registration has not
occurred:

     The Grantee hereby agrees, warrants and represents that Grantee is acquiring the Common Stock
to be issued pursuant to this Agreement for Grantee’s own account for investment purposes only, and
not with a view to, or in connection with, any resale or other distribution of any of such shares,
except as hereafter permitted. The Grantee further agrees that Grantee will not at any time make
any offer, sale, transfer, pledge or other disposition of such Common Stock to be issued hereunder
without an effective registration statement under the Securities Act and under any applicable state
securities laws or an opinion of counsel acceptable to the Company to the effect that the proposed
transaction will be exempt from such registration. The Grantee shall execute such instruments,
representations, acknowledgments and agreements as the Company may, in its sole discretion, deem
advisable to avoid any violation of federal, state, local or securities exchange rule, regulation
or law.

     The certificates for Common Stock to be issued pursuant to this Agreement shall bear the
following securities legend (the “Securities Legend”):

The shares represented by this certificate have not been registered
under the Securities Act of 1933, as amended, or under applicable
state securities laws. The shares have been acquired for investment
and may not be offered, sold, transferred, pledged or otherwise
disposed of without an effective registration statement under the
Securities Act of 1933, as amended, and under any applicable state
securities laws or an opinion of counsel acceptable to the Company
that the proposed transaction will be exempt from such registration.

The Securities Legend shall be removed upon registration of the legended shares under the
Securities Act and under any applicable state laws or upon receipt of any opinion of counsel
acceptable to the Company that said registration is no longer required.

     The sole purpose of the agreements, warranties, representations and legend set forth in the
two immediately preceding paragraphs is to prevent violations of the Securities Act and any
applicable state securities laws.

     5. Grantee’s Rights. Except as otherwise provided herein, the Grantee, as owner of the
Shares, shall have all rights of a stockholder. During any Restricted Period, the Grantee shall be
entitled to vote such Shares as to which the Restricted Period has not yet lapsed or expired (the
“Restricted Shares”) in Grantee’s sole discretion upon any matters coming before any annual and
special meetings of the stockholders of the Company and at any continuations and adjournments of
such meetings.

2

 

     6. Cash Dividends. Cash dividends, if any, paid on the Restricted Shares shall be held
by the Company for the account of the Grantee and paid to the Grantee upon the expiration of the
Restricted Period or upon the death or disability of the Grantee. All such withheld dividends shall
earn interest at an annual rate determined by the Board of Directors of the Company.

     7. Expiration of Restricted Period. Upon the lapse or expiration of the Restricted
Period with respect to any portion of the Shares, the Company shall deliver to the Grantee (or in
the case of a deceased Grantee, to Grantee’s legal representative) the certificate in respect of
such Shares pursuant to Section 4 above. The Shares as to which the Restricted Period shall have
lapsed or expired shall be free of the restrictions referred to in Section 2 above. Notwithstanding
the foregoing, the Securities Legend described in Section 4 shall continue to be included on the
certificates as long as registration has not occurred.

     8. Adjustments for Changes in Capitalization of the Company. In the event of any
change in the outstanding shares of Common Stock without the receipt of consideration by the
Company (through merger, consolidation, reorganization, recapitalization, reincorporation, stock
dividend, dividend in property other than cash, stock split, liquidating dividend, combination of
shares, exchange of shares, change in corporate structure or other transaction not involving the
receipt of consideration by the Company), the number of Restricted Shares shall be appropriately
adjusted. The Board of Directors, whose determination shall be final, binding and conclusive, shall
make such adjustments. Any shares of Common Stock or other securities received, as a result of the
foregoing, by the Grantee with respect to Shares subject to the restrictions contained in Section 2
above also shall be subject to such restrictions and the certificate or other instruments
representing or evidencing such shares or securities shall be legended and deposited with the
Company in the manner provided in Section 4 above.

     9. Change in Control. The following shall apply in the event of a change of control.

          (a) Dissolution or Liquidation — In the event of a dissolution or liquidation of the
Company, then this Award shall terminate immediately prior to, or simultaneously with, such event.

          (b) Asset Sale, Merger, Consolidation or Reverse Merger — In the event of (i) a sale
of all or substantially all of the assets of the Company, (ii) a merger in which the Company is not
the surviving corporation or (iii) a reverse merger in which the Company is the surviving
corporation but the shares of Common Stock outstanding immediately preceding the merger are
converted by virtue of the merger into other property, whether in the form of securities, cash or
otherwise, then any surviving corporation or acquiring corporation shall assume this Award, if
outstanding under the Plan or shall substitute similar awards (including an award to acquire the
same consideration paid to the stockholders in the transaction described in this Section 9(b) for
this Award, if outstanding under the Plan). In the event any surviving corporation or acquiring
corporation refuses to assume this Award or to substitute similar awards for this Award, if
outstanding under the Plan, then the vesting of the Shares shall be accelerated in full, and this
Award shall terminate at or prior to such event.

3

 

          (c) Other Change of Control — In the event of the happening of any of the following
events: (1) a change within a twelve-month period in the holders of more than 50% of the
outstanding voting stock of the Company (other than by means provided for in this Section 9 and as
provided for in Section 10.3 of the Plan); or (2) any other event deemed to constitute a “Change of
Control” by the Board of Directors (other than by means provided for in Sections 9(a) and 9(b)
above and as provided for in Sections 10.2 and 10.3 of the Plan), the vesting of the Shares shall
be accelerated in full.

     10. Delivery and Registration of Shares of Common Stock. The Company’s obligation to
deliver Shares hereunder shall be conditioned upon the receipt of a representation as to the
investment intention of the Grantee or any other person to whom such Shares are to be delivered, in
such form as the Board of Directors shall determine to be necessary or advisable to comply with the
provisions of the Securities Act or any other federal, state or local securities legislation or
regulation. Any representation regarding investment intent shall become inoperative upon the
registration of such shares or other action eliminating the necessity of such representation under
such Securities Act or other securities regulation.

     The Company shall not be required to deliver any Shares under the Plan prior to (i) the
admission of such Shares to listing on any stock exchange on which the Shares of Common Stock may
then be listed, and (ii) the completion of such registration or other qualification of such Shares
under any state or federal law, rule or regulation, as the Board of Directors shall determine to be
necessary or advisable.

     11. Plan and Plan Interpretations as Controlling. The Shares hereby awarded and the
terms and conditions herein set forth are subject in all respects to the terms and conditions of
the Plan, which are controlling. All determinations and interpretations by the Board of Directors
shall be binding and conclusive upon the Grantee or Grantee’s legal representatives with regard to
any question arising hereunder or under the Plan.

     12. Grantee Service. Nothing in this Agreement shall limit the right of the Company or
any of its Affiliates to terminate the Grantee’s service as an officer, employee, director or
otherwise impose upon the Company or any of its Affiliates any obligation to employ or accept the
services of the Grantee.

     13. Withholding and Social Security Taxes. Upon the termination of any Restricted
Period with respect to any Shares (or any such earlier time, if any, that an election is made under
Section 83(b) of the Internal Revenue Code of 1986, as amended (the “Code”), or any successor
provision thereto, to include the value of such Shares in taxable income), (i) the Company may
deduct or withhold (or cause to be deducted or withheld) from any payment or distribution to the
Grantee whether or not pursuant to the Plan or (ii) the Company may require that the Grantee remit
cash to the Company (through payroll deduction or otherwise), in each case in an amount sufficient
in the opinion of the Company to satisfy such withholding obligation. If the event giving rise to
the withholding obligation involves a transfer of shares of Common Stock, then, at the discretion
of the Board of Directors, the Grantee may satisfy the withholding obligation described under this
Section 13 by electing to have the Company withhold shares of Common Stock (which withholding shall
be at a rate not in excess of the statutory minimum rate) or by tendering previously owned shares
of Common Stock, in each case having a Fair Market Value (as defined in the Plan) equal to the amount of tax to be withheld (or by another mechanism as
may be required or appropriate to conform with local tax and other rules). The Company shall
withhold from any cash dividends paid on the Restricted Stock an amount sufficient to cover taxes
owed as a result of the dividend payment.

4

 

     14. Tax Consequences. Grantee has reviewed with Grantee’s own tax advisors the
federal, state, local and foreign tax consequences of this investment and the transactions
contemplated by this Agreement. Grantee is relying solely on such advisors and not on any
statements or representations of Company or any of its agents. Grantee understands that Grantee
(and not Company) shall be responsible for Grantee’s own tax liability that may arise as a result
of this investment or the transactions contemplated by this Agreement. Grantee understands that
Section 83 of the Code, taxes (as ordinary income) the fair market value of the Shares as of the
date any “restrictions” on the Shares lapse. To the extent that a grant hereunder is not otherwise
an exempt transaction for purposes of Section 16(b) of the Securities and Exchange Act of 1934 (the
“1934 Act”), with respect to officers, directors and 10% shareholders, a “restriction” on the
Shares includes for these purposes the period after the grant of the Shares during which such
officers, directors and 10% shareholders could be subject to suit under Section 16(b) of the 1934
Act. Alternatively, Grantee understands that Grantee may elect to be taxed at the time the Shares
are granted rather than when the restrictions on the Shares lapse, or the Section 16(b) period
expires, by filing an election under Section 83(b) of the Code with the I.R.S. within 30 days from
the date of grant.

     GRANTEE ACKNOWLEDGES THAT IT IS GRANTEE’S SOLE RESPONSIBILITY AND NOT THE COMPANY’S TO FILE
TIMELY THE ELECTION AVAILABLE TO GRANTEE UNDER SECTION 83(B) OF THE CODE, EVEN IF GRANTEE REQUESTS
THAT THE COMPANY OR ITS REPRESENTATIVES MAKE THIS FILING ON GRANTEE’S BEHALF.

     15. Amendment/Choice of Law. This Agreement constitutes the entire understanding
between the Company and the Grantee with respect to the subject matter hereof and no amendment,
supplement or waiver of this Agreement, in whole or in part, shall be binding upon the Company
unless in writing and signed by the Chief Financial Officer of the Company with the approval of the
Board of Directors. This Agreement and the performances of the parties hereunder shall be construed
in accordance with and governed by the laws of the State of Delaware.

     16. Defined Terms. Unless otherwise defined herein, capitalized terms used herein
shall have the meanings ascribed to them in the Plan.

     17. Grantee Acceptance. The Grantee shall signify Grantee’s acceptance of the terms
and conditions of this Agreement by signing in the space provided below and returning a signed copy
of this Agreement to the Chief Financial Officer of the Company. IF A FULLY EXECUTED COPY HEREOF
HAS NOT BEEN RECEIVED BY THE CHIEF FINANCIAL OFFICER OF THE COMPANY, THE COMPANY HAS THE RIGHT TO
REVOKE THIS AWARD, AND AVOID ALL OBLIGATIONS UNDER THIS AGREEMENT.

5

 

     IN WITNESS WHEREOF, the parties hereto have caused this STOCK BONUS AWARD AGREEMENT to be
executed as of the date first above written.

	 	 	 	 	 
	 	IMPAX LABORATORIES, INC.

 	 
	 
	 	By:  	 	 
	 	 	Arthur A. Koch, Jr.       	 
	 	 	Chief Financial Officer 	 
	 

	 	 	 	 	 
	 

	 	ACCEPTED:
	 	 
	 
	 
	 	 	 	 
	 

	 	 	 	 
	 

	 	(Signature)	 	 
	 
	 	 	 	 
	 
	 

	 	 	 	 
	 

	 	(Date)	 	 

PLEASE SIGN AND DATE THIS PAGE

AND RETURN TO

ART KOCH’S OFFICE

IN CHALFONT, PA

6

 

Attachment A to Stock Bonus Award Agreement 

Stock Power

     For value received, I hereby sell, assign, and transfer to Impax Laboratories, Inc. (the
“Corporation”)                      shares of the common stock of the Corporation, standing in my name on
the books and records of the aforesaid Corporation, represented by Certificate No. ___ and do
hereby irrevocably constitute and appoint the Secretary of the Corporation attorney, with full
power of substitution, to transfer this stock on the books and records of the aforesaid
Corporation.

	 	 	 	 	 
	 
	 

	 	 

	 	 

Dated:

In the presence of:

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