Escrow Agreement {S.A. 12}

S.A. 12 (1971) COMMONWEALTH OF VIRGINIA STATE CORPORATION COMMISSION DIVISION OF SECURITIES AND RETAIL FRANCHISING ESCROW AGREEMENT As a condition of the registration approved by the Commissions order dated ________________________________________ of securities to be issued by ________________________________________ the owners of the hereinafter-d escribed securities hereby deliver the certificates or other evidence of said sec urities in escrow to ________________________________________ to hold subject to the provisio ns of Section 13.1-510(h) of the Code of Virginia. The undersigned securityholders agree to deliver to the escrow agent any additional or different securities received by them as a result of a stock dividend, s tock split, merger or consolidation and agree to refrain from voting any securities deposited hereinunder in favor of a merger or consolidation. The undersigned issuer agrees to the condition s set forth above and agrees to deliver such additional or different securities to the escrow agent. The undersigned depository agrees not to release from escrow any of the securities excep t on order of the State Corporation Commission. by President Escrow agent by TitleSignature of stockholders Number of Shares Certificate Nos. American LegalNet, Inc. www.USCourtForms.com