e of transferee) Oteritrss of transfer) tecum(vr an! itrrei) (ail Sr•14 da Zip rile) from (name ofgrantor)(Pr(nt or we), (fiffiress of grantot) OrlimbentnIscrert) tic% Seal an d Zip roe) Extent of Authority (if licensing agreement): Date of Transfer: Signature of grantor an MO Pagc2 or 4 EFTA00011801 E