Form: S-1/A

General form of registration statement for all companies including face-amount certificate companies

April 28, 2017

Documents

Exhibit 4.1

 

LOGO

The following abbreviations, when used in the inscription on the face of this certificate, shall be construed as though they were written out in full according to applicable laws or regulations:

 

    TEN COM

          —      as tenants in common

    TEN ENT

          —      as tenants by the entireties

    JT TEN

          —      as joint tenants with right of
      survivorship and not as tenants
      in common

UNIF GIFT MIN ACT  — 

   .................... Custodian .........................
        (Cust)                           (Minor)
  under Uniform Gifts to Minors
  Act ........................................................
                              (State)

UNIF TRF MIN ACT  —

   ................ Custodian (until age ............)
      (Cust)
  ....................... under Uniform Transfers
      (Minor)
  to Minors Act .........................................
                                       (State)
 

 

Additional abbreviations may also be used though not in the above list.

FOR VALUE RECEIVED,                                               hereby sell, assign and transfer unto

 

PLEASE INSERT SOCIAL SECURITY OR OTHER    
IDENTIFYING NUMBER OF ASSIGNEE    
     
     
         
(PLEASE PRINT OR TYPEWRITE NAME AND ADDRESS, INCLUDING ZIP CODE, OF ASSIGNEE)
 
 
    Shares
of the common stock represented by the within Certificate, and do hereby irrevocably constitute and appoint  
    Attorney
to transfer the said stock on the books of the within named Corporation with full power of substitution in the premises.  
Dated                                                                  

 

 

X

  

 
 

X

  

 
 

NOTICE:

   THE SIGNATURE(S) TO THIS ASSIGNMENT MUST CORRESPOND WITH THE NAME(S) AS WRITTEN UPON THE FACE OF THE CERTIFICATE IN EVERY PARTICULAR, WITHOUT ALTERATION OR ENLARGEMENT OR ANY CHANGE WHATEVER.

 

Signature(s) Guaranteed

 

By

    
THE SIGNATURE(S) SHOULD BE GUARANTEED BY AN ELIGIBLE GUARANTOR INSTITUTION (BANKS, STOCKBROKERS, SAVINGS AND LOAN ASSOCIATIONS AND CREDIT UNIONS WITH MEMBERSHIP IN AN APPROVED SIGNATURE GUARANTEE MEDALLION PROGRAM), PURSUANT TO S.E.C. RULE 17Ad-15.