You are on page 1of 2

reaties.

IT IS ILLEGAL AND STRICTLY PROHIBITED TO DISTRIBUTE, PUBLISH, OFFER FOR SALE, LICENSE OR SUBLICENSE, GIVE OR DISCLOS

Canada and by international treaties. IT IS ILLEGAL AND STRICTLY PROHIBITED TO DISTRIBUTE, PUBLISH, OFFER F

Copyright Envision Corporation. 2002. All rights reserved. Protected by the copyright laws of the United States & Canada and by international treaties. IT IS ILLEGAL AND STRICTLY PROHIBITED TO DISTRIBUTE, PUBLISH, OFFER FOR SALE, LICENSE OR SUBLICENSE, GIVE OR DISCLOSE TO ANY OTHER PARTY, THIS PRODUCT IN HARD COPY OR DIGITAL FORM. ALL OFFENDERS WILL BE SUED IN A COURT OF LAW.

AFFIDAVIT OF LOST STOCK CERTIFICATE

This Affidavit of Lost Stock Certificate (the Agreement) is made and effective [DATE], BETWEEN: [COMPANY NAME] (the "Company"), a corporation organized and existing under the laws of the [STATE/PROVINCE], with its head office located at:

AND:

[STOCKHOLDER NAME] (the "Stockholder"), an individual/ a corporation organized and existing under the laws of the [STATE/PROVINCE], with its head office located at:

TERMS The undersigned Stockholder hereby declares, under penalty of perjury, as follows: 1. The undersigned is the owner of a total of [NUMBER OF SHARES] shares of the Common Stock of [NAME OF COMPANY], Inc., a [STATE WHERE COMPANY INCORPORATED] corporation (the Company). 2. The undersigned has examined his, her or its records and, after diligent search, is unable to find the certificate or certificates representing such shares (the Certificates) and believes that the Certificates were lost. 3. The undersigned has not transferred, sold, encumbered, or pledged any of the shares represented by the Certificates. 4. The undersigned releases the Company and any successor from any and all liability relating to the loss of the Certificates, or the issuance of new Certificates. The undersigned agrees to defend and indemnify and hold harmless the Company and any successor from any damage or loss caused by the loss of the Certificates. 5. In the event of discovery of the original Certificates, the undersigned agrees to return them promptly to the Company or any successor, marked CANCELLED. IN WITNESS WHEREOF, the parties hereto have executed this Agreement on the date first above written. COMPANY STOCKHOLDER

Authorized Signature

Authorized Signature

Print Canada and byPrint Name andtreaties. IT IS ILLEGAL AND STRICTLYName and Title TO DISTRIBUTE, PUBLISH, OFFER international Title PROHIBITED

Affidavit of Lost Stock Certificate

Page 1

of 2

? Copyright Envision Corporation. 2002. All rights reserved. Protected by the copyright laws of the United States and Canada and by internatio

Copyright Envision Corporation. 2002. All rights reserved. Protected by the copyright laws of the United States & Canada and by international treaties. IT IS ILLEGAL AND STRICTLY PROHIBITED TO DISTRIBUTE, PUBLISH, OFFER FOR SALE, LICENSE OR SUBLICENSE, GIVE OR DISCLOSE TO ANY OTHER PARTY, THIS PRODUCT IN HARD COPY OR DIGITAL FORM. ALL OFFENDERS WILL BE SUED IN A COURT OF LAW.

Affidavit of Lost Stock Certificate

Page 2

of 2