ANNEX C
ASSIGNMENT
FORM
FOR
VALUE
RECEIVED the undersigned registered owner of this Warrant hereby sells, assigns
and transfers unto the Assignee named below all of the rights of the undersigned
under this Warrant, with respect to the number of shares of Common Stock set
forth below:
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Name
and Address of Assignee
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No.
of Shares of
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Common
Stock
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and
does
hereby irrevocably constitute and appoint _______________________
attorney-in-fact to register such transfer onto the books of LaPolla Industries,
Inc. maintained for the purpose, with full power of substitution in the
premises.
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Dated:
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Print
Name:
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Signature:
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Witness:
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NOTICE:
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The
signature on this assignment must correspond with the name as written
upon
the face of this Warrant in every particular, without alteration
or
enlargement or any change
whatsoever.
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