Wreckfish Shareholder Certificate Transfer Form

U. S. Department of Commerce, NOAA
National Marine Fisheries Service
263 13th Avenue South
St. Petersburg, FL 33701

Certificate No. number
This is to Certify that shareholder holds
shares percentage shares of the Wreckfish Fishery transferable
only on the books of the National Marine Fisheries Service,
Southeast Region, by the holder hereof upon
Surrender of this certificate properly endorsed.
Witness, the signatures of its duly authorized officers

_____________________________________________________________
Transfer Agent

_____________________________________________________________
Regional Administrator

____________________________________________
Date
Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to
comply with an information collection subject to the requirements of the Paperwork Reduction Act of 1995 unless the information collection
has a currently valid OMB Control Number. The approved OMB Control Number for this information collection is 0648-0551. Without this
approval, we could not conduct this information collection. Public reporting for this information collection is estimated to be approximately 20
minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the information collection. All responses to this information collection are required to obtain or retain
benefits. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing
this burden to the PRA Officer, National Marine Fisheries Service, 263 13th Ave South, St. Petersburg, FL 33701. The National Marine Fisheries
Service requires this information for the conservation and management of marine fishery resources. The data reported will be used to develop,
implement, and monitor fishery management activities for a variety of other uses. Responses to this collection are required to obtain or retain a
fisheries permit under the Magnuson-Stevens Act. Information submitted will be submitted as confidential in accordance with NOAA
Administrative Order 216-100, Protection of Confidential Fishery Statistics.

OMB Control Number:
0648-0551 Approval Expires:
5/31/2021

For the value of $____________, I (we) hereby sell, assign, and transfer unto:
Name(s): _____________________________________________________________________________________
First, Middle, and Last Name(s) or Name of Business* as will appear on the certificate

Mailing Address: ______________________________________________________________________________
City/State/ZIP Code: ___________________________________________________________________________
_____________________________

_______________________________ ____________________________

Tax ID # (Federal Tax ID or SSN)

Date of Birth or Date Business Filed
(MM/DD/YYYY)

(Area code) Phone Number

*If the shareholder’s certificate is owned by a business, then complete this section for each officer and shareholder associated with the
business. Please attach additional sheets as necessary to list all officers, directors, shareholders, and registered agents of the business.
Position held – check ALL that apply
President ____ Vice President ____ Secretary____ Treasurer____ Director/Manager____ Shareholder____ Other_____
Percent (%) of corporation held ______________

Name: _______________________________________________________________________________________
First, Middle, and Last Name

Mailing Address: ______________________________________________________________________________
City/State/ZIP Code: ___________________________________________________________________________
_____________________________
Tax ID # (Federal Tax ID or SSN)

_______________________________ ____________________________
Date of Birth or Date Business Filed
(MM/DD/YYYY)

(Area code) Phone Number

________ percentage shares represented by the within certificate and do hereby irrevocably constitute and appoint
the Transfer Agent to transfer the said shares on the books of the National Marine Fisheries Service, Southeast
Region
____________________________________________________________________________________________
Buyer’s Signature

Position

Date

____________________________________________________________________________________________
Additional Buyer, if held jointly

Position

Date

____________________________________________________________________________________________
Seller’s Signature

Position

Date

____________________________________________________________________________________________
Additional Seller, if held jointly

Position

Date

NOTARY PUBLIC: The above instrument was acknowledged before me this ______ day of __________________ ________.
Day

Month

Year

by ________________________________________________________ who is personally known to me or who has produced
Name of certificate seller

_____________________________________________________________________________________ as identification.
Type of identification

___________________________________________________________________, Notary
Signature of Notary Public

Public Commission Number: _______________________

__________________________________________________________________
Name of Notary typed, printed or stamped

Any or all share certificates previously issued in the name of any Buyer(s) named above must be enclosed herewith for reissue
pursuant to this transfer.