DECLARATION OF TRUST

AND ASSIGNMENT OF STOCK

KNOW ALL MEN BY THESE PRESENTS:

I, __________, of legal age, citizen of __________, and with address at

_________________, do hereby acknowledge that I hold in trust for _______________,
(the “Owner”) ________ shares of stock (the “Shares”) of ________________ (the
“Corporation”) which is registered in my name in the books of the Corporation. I
further confirm that I received said Shares in trust from the Owner for the sole purpose
of qualifying me to act as a director of the Corporation or to perform any act in relation
to the Corporation on behalf the Owner, and that the Owner received no consideration
for its assignment of said Shares to me other than my undertaking to represent said
Owner in the Corporation.

As trustee of the Owner, I bind myself to: (i) duly account for and pay to the
Owner all dividends paid or issued to me by reason of my holding the Shares and
hereby authorize the Corporate Secretary of the Corporation to credit in favor of the
Owner all dividends, whether cash, stock or otherwise, declared on the Shares; and (ii)
to exercise my voting rights in respect of the Shares as the Owner shall direct.

NOW, THEREFORE, I do hereby irrevocably constitute and appoint the

Corporate Secretary of the Corporation as my true and lawful attorney-in-fact, for me
and in my name, place and stead, to sell, assign, and transfer the Shares in favor of the
Owner or its nominee(s), and for that purpose to make and execute all necessary acts of
assignment and transfer thereof and to substitute one or more persons with like power,
hereby ratifying and confirming all that my said attorney-in-fact or his substitute(s)
shall lawfully do by virtue thereof.

IN WITNESS WHEREOF, I have hereunto set my hand this __ day of ________,

2019 at ___________.

_________________

Signed in the Presence of:

_______________________ _________________________