ANIKA THERAPEUTICS INC
EX-10
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<DESCRIPTION>EX-10
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<p align="right" style="font-weight:bold;margin:0pt 0pt 12.0pt;text-align:right;"><b><font size="2" face="Times New Roman" style="font-size:10.0pt;">Exhibit&nbsp;10.1</font></b></p>

<p style="font-weight:bold;margin:0pt 0pt 12.0pt;text-align:center;"><b><font size="2" face="Times New Roman" style="font-size:10.0pt;">STOCK
APPRECIATION RIGHT AGREEMENT<br>
(For Stock-Settled SAR&#146;s)</font></b></p>

<p style="font-weight:bold;margin:0pt 0pt 12.0pt;text-align:center;"><b><font size="2" face="Times New Roman" style="font-size:10.0pt;">UNDER
ANIKA THERAPEUTICS, INC.<br>
2003 STOCK OPTION AND INCENTIVE PLAN</font></b></p>

<p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">Name of Grantee:________________________________</font></p>

<p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">No.&nbsp;of Stock
Appreciation Rights:_____________________________</font></p>

<p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">Exercise Price per
Share:____________________</font></p>

<p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">Grant
Date:______________________________</font></p>

<p style="margin:0pt 0pt 12.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">Expiration Date:_________________________________</font></p>

<p style="margin:24.0pt 0pt 12.0pt;text-indent:36.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">Pursuant to the Anika
Therapeutics,&nbsp;Inc. 2003 Stock Option and Incentive Plan, as amended
through the date hereof (the &#147;Plan&#148;), Anika Therapeutics,&nbsp;Inc. (the &#147;Company&#148;)
hereby grants to the Grantee named above the number of Stock Appreciation
Rights (as defined in the Plan) specified above (the &#147;SAR&#146;s&#148;). Each of the SAR&#146;s
granted herein relates to one share of Common Stock, par value $0.01 per share
(the &#147;Stock&#148;), of the Company. This Agreement shall give the Grantee the right
to exercise on or prior to the Expiration Date specified above all or part of
the number of SAR&#146;s specified above at the Exercise Price per Share specified above
and to receive shares of Stock as payment therefor in accordance with paragraph
2 of this Agreement, subject to the terms and conditions set forth herein and
in the Plan.</font></p>

<h1 style="font-weight:normal;margin:0pt 0pt 12.0pt;page-break-after:avoid;text-indent:36.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">1.&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; <u>Exercisability Schedule</u>. No SAR&#146;s may be
exercised until they have become exercisable. Except as set forth below, and
subject to the discretion of the Administrator (as defined in Section&nbsp;2 of
the Plan) to accelerate the exercisability schedule hereunder, these SAR&#146;s
shall be exercisable with respect to the following number of Shares on the
dates indicated: </font></h1>

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<table border="0" cellspacing="0" cellpadding="0" style="border-collapse:collapse;">
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  <td width="50" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:37.5pt;">
  <p style="font-size:8.0pt;font-weight:bold;line-height:8.0pt;margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:center;"></p>
  </td>
  <td width="87" valign="bottom" style="border:none;border-bottom:solid windowtext 1.0pt;padding:0pt .7pt 0pt 0pt;width:64.95pt;">
  <p style="font-weight:bold;line-height:8.0pt;margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:center;"><b><font size="1" face="Times New Roman" style="font-size:8.0pt;">Number&nbsp;of<br>
  SAR&#146;s&nbsp;Exercisable</font></b></p>
  </td>
  <td width="50" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:37.55pt;">
  <p style="font-weight:bold;line-height:8.0pt;margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:center;"><b><font size="1" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></b></p>
  </td>
  <td width="16" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:12.0pt;">
  <p style="font-weight:bold;line-height:8.0pt;margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:center;"><b><font size="1" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></b></p>
  </td>
  <td width="88" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:65.8pt;">
  <p style="font-weight:bold;line-height:8.0pt;margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:center;"><b><font size="1" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></b></p>
  </td>
  <td width="53" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:40.0pt;">
  <p style="font-weight:bold;line-height:8.0pt;margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:center;"><b><font size="1" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></b></p>
  </td>
  <td width="88" valign="bottom" style="border:none;border-bottom:solid windowtext 1.0pt;padding:0pt .7pt 0pt 0pt;width:65.8pt;">
  <p style="font-weight:bold;line-height:8.0pt;margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:center;"><b><font size="1" face="Times New Roman" style="font-size:8.0pt;">Exercisability&nbsp;Date</font></b></p>
  </td>
  <td width="27" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:20.0pt;">
  <p style="font-weight:bold;line-height:8.0pt;margin:0pt 0pt .0001pt;text-align:center;"><b><font size="1" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></b></p>
  </td>
 </tr>
 <tr>
  <td width="50" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:37.5pt;">
  <p style="font-weight:bold;line-height:8.0pt;margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:center;"><b><font size="1" face="Times New Roman" style="font-size:8.0pt;">&nbsp;</font></b></p>
  </td>
  <td width="87" valign="bottom" style="border:none;padding:0pt .7pt 0pt 0pt;width:64.95pt;">
  <p style="font-weight:bold;line-height:8.0pt;margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:center;"><b><font size="1" face="Times New Roman" style="font-size:8.0pt;">&nbsp;</font></b></p>
  </td>
  <td width="50" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:37.55pt;">
  <p style="font-weight:bold;line-height:8.0pt;margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:center;"><b><font size="1" face="Times New Roman" style="font-size:8.0pt;">&nbsp;</font></b></p>
  </td>
  <td width="16" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:12.0pt;">
  <p style="font-weight:bold;line-height:8.0pt;margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:center;"><b><font size="1" face="Times New Roman" style="font-size:8.0pt;">&nbsp;</font></b></p>
  </td>
  <td width="88" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:65.8pt;">
  <p style="font-weight:bold;line-height:8.0pt;margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:center;"><b><font size="1" face="Times New Roman" style="font-size:8.0pt;">&nbsp;</font></b></p>
  </td>
  <td width="53" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:40.0pt;">
  <p style="font-weight:bold;line-height:8.0pt;margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:center;"><b><font size="1" face="Times New Roman" style="font-size:8.0pt;">&nbsp;</font></b></p>
  </td>
  <td width="88" valign="bottom" style="border:none;padding:0pt .7pt 0pt 0pt;width:65.8pt;">
  <p style="font-weight:bold;line-height:8.0pt;margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:center;"><b><font size="1" face="Times New Roman" style="font-size:8.0pt;">&nbsp;</font></b></p>
  </td>
  <td width="27" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:20.0pt;">
  <p style="font-weight:bold;line-height:8.0pt;margin:0pt 0pt .0001pt;text-align:center;"><b><font size="1" face="Times New Roman" style="font-size:8.0pt;">&nbsp;</font></b></p>
  </td>
 </tr>
 <tr bgcolor="#CCEEFF">
  <td width="187" colspan="3" valign="top" style="padding:0pt .7pt 0pt 0pt;width:140.0pt;">
  <p style="margin:0pt 0pt .0001pt 10.0pt;page-break-after:avoid;text-indent:-10.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">0</font></p>
  </td>
  <td width="16" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:12.0pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="88" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:65.8pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:right;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">(0</font></p>
  </td>
  <td width="53" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:40.0pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">%)</font></p>
  </td>
  <td width="88" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:65.8pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:right;"><b><font size="2" face="Times New Roman" style="font-size:10.0pt;font-weight:bold;">[Grant Date]</font></b></p>
  </td>
  <td width="27" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:20.0pt;">
  <p style="margin:0pt 0pt .0001pt;"><b><font size="2" face="Times New Roman" style="font-size:1.0pt;font-weight:bold;">&nbsp;</font></b></p>
  </td>
 </tr>
 <tr>
  <td width="187" colspan="3" valign="top" style="padding:0pt .7pt 0pt 0pt;width:140.0pt;">
  <p style="margin:0pt 0pt .0001pt 10.0pt;page-break-after:avoid;text-indent:-10.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="16" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:12.0pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="88" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:65.8pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:right;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="53" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:40.0pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="88" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:65.8pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:right;"><b><font size="2" face="Times New Roman" style="font-size:10.0pt;font-weight:bold;">&nbsp;</font></b></p>
  </td>
  <td width="27" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:20.0pt;">
  <p style="margin:0pt 0pt .0001pt;"><b><font size="2" face="Times New Roman" style="font-size:10.0pt;font-weight:bold;">&nbsp;</font></b></p>
  </td>
 </tr>
 <tr bgcolor="#CCEEFF">
  <td width="187" colspan="3" valign="top" style="padding:0pt .7pt 0pt 0pt;width:140.0pt;">
  <p style="margin:0pt 0pt .0001pt 10.0pt;page-break-after:avoid;text-indent:-10.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">_____________</font></p>
  </td>
  <td width="16" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:12.0pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="88" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:65.8pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:right;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">(25</font></p>
  </td>
  <td width="53" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:40.0pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">%)</font></p>
  </td>
  <td width="88" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:65.8pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:right;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">____________</font></p>
  </td>
  <td width="27" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:20.0pt;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr>
  <td width="187" colspan="3" valign="top" style="padding:0pt .7pt 0pt 0pt;width:140.0pt;">
  <p style="margin:0pt 0pt .0001pt 10.0pt;page-break-after:avoid;text-indent:-10.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="16" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:12.0pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="88" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:65.8pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:right;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="53" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:40.0pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="88" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:65.8pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:right;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="27" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:20.0pt;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr bgcolor="#CCEEFF">
  <td width="187" colspan="3" valign="top" style="padding:0pt .7pt 0pt 0pt;width:140.0pt;">
  <p style="margin:0pt 0pt .0001pt 10.0pt;page-break-after:avoid;text-indent:-10.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">_____________</font></p>
  </td>
  <td width="16" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:12.0pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="88" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:65.8pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:right;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">(50</font></p>
  </td>
  <td width="53" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:40.0pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">%)</font></p>
  </td>
  <td width="88" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:65.8pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:right;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">____________</font></p>
  </td>
  <td width="27" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:20.0pt;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr>
  <td width="187" colspan="3" valign="top" style="padding:0pt .7pt 0pt 0pt;width:140.0pt;">
  <p style="margin:0pt 0pt .0001pt 10.0pt;page-break-after:avoid;text-indent:-10.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="16" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:12.0pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="88" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:65.8pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:right;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="53" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:40.0pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="88" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:65.8pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:right;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="27" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:20.0pt;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr bgcolor="#CCEEFF">
  <td width="187" colspan="3" valign="top" style="padding:0pt .7pt 0pt 0pt;width:140.0pt;">
  <p style="margin:0pt 0pt .0001pt 10.0pt;page-break-after:avoid;text-indent:-10.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">_____________</font></p>
  </td>
  <td width="16" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:12.0pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="88" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:65.8pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:right;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">(75</font></p>
  </td>
  <td width="53" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:40.0pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">%)</font></p>
  </td>
  <td width="88" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:65.8pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:right;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">____________</font></p>
  </td>
  <td width="27" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:20.0pt;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
 </tr>
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  <td width="187" colspan="3" valign="top" style="padding:0pt .7pt 0pt 0pt;width:140.0pt;">
  <p style="margin:0pt 0pt .0001pt 10.0pt;page-break-after:avoid;text-indent:-10.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
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  <td width="16" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:12.0pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
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  <td width="88" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:65.8pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:right;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="53" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:40.0pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="88" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:65.8pt;">
  <p style="margin:0pt 0pt .0001pt;page-break-after:avoid;text-align:right;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="27" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:20.0pt;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr bgcolor="#CCEEFF">
  <td width="187" colspan="3" valign="top" style="padding:0pt .7pt 0pt 0pt;width:140.0pt;">
  <p style="margin:0pt 0pt .0001pt 10.0pt;text-indent:-10.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">_____________</font></p>
  </td>
  <td width="16" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:12.0pt;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="88" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:65.8pt;">
  <p style="margin:0pt 0pt .0001pt;text-align:right;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">(100</font></p>
  </td>
  <td width="53" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:40.0pt;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">%)</font></p>
  </td>
  <td width="88" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:65.8pt;">
  <p style="margin:0pt 0pt .0001pt;text-align:right;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">____________</font></p>
  </td>
  <td width="27" valign="bottom" style="padding:0pt .7pt 0pt 0pt;width:20.0pt;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
 </tr>
</table>

</div>

<p style="margin:12.0pt 0pt;text-indent:36.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">Once exercisable, these
SAR&#146;s shall continue to be exercisable at any time or times prior to the close
of business on the Expiration Date, subject to the provisions hereof and of the
Plan.</font></p>

<br><hr size="3" width="100%" noshade color="#010101" align="center">

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<p style="margin:12.0pt 0pt;text-indent:36.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">Upon
the occurrence of a Change of Control as defined in Section&nbsp;17 of the
Plan, each Stock Appreciation Right granted hereunder shall automatically
become fully exercisable.</font></p>

<h1 style="font-weight:normal;margin:0pt 0pt 12.0pt;page-break-after:avoid;text-indent:36.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">2.&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; <u>Manner of Exercise</u>.</font></h1>

<h2 style="font-weight:normal;margin:0pt 0pt 12.0pt 18.0pt;page-break-after:avoid;text-indent:72.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">(a)&#160;&#160; The Grantee may exercise any exercisable SAR&#146;s
only in the following manner:&#160; from time
to time on or prior to the Expiration Date of the SAR&#146;s, the Grantee may give
written notice to the Administrator of his or her election to exercise some or
all of the SAR&#146;s exercisable at the time of such notice. This notice shall
specify the number of SAR&#146;s to be exercised.</font></h2>

<p style="margin:0pt 0pt 12.0pt;text-indent:36.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">The delivery of certificates representing the SAR
Shares will be contingent upon any agreement, statement or other evidence that
the Company may require to satisfy itself that the issuance of Stock to be delivered
pursuant to the exercise of SAR&#146;s under the Plan and any subsequent resale of
the shares of Stock will be in compliance with applicable laws and regulations.</font></p>

<h2 style="font-weight:normal;margin:0pt 0pt 12.0pt 18.0pt;page-break-after:avoid;text-indent:72.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">(b)&#160;&#160; The Grantee shall thereupon receive a payment
equal to the product of (i)&nbsp;the Fair Market Value of a share of Stock on
the date of exercise less the Exercise Price per Share specified in this
Agreement, multiplied by (ii)&nbsp;the number of SAR&#146;s exercised. Such payment
shall be in the form of shares of Stock valued at the Fair Market Value of a
share of stock on the date of exercise. Any fractional shares shall be paid in
cash.</font></h2>

<p style="margin:0pt 0pt 12.0pt;text-indent:36.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">Certificates for shares of Stock shall be issued and
delivered to the Grantee upon compliance to the satisfaction of the
Administrator with all requirements under applicable laws or regulations in
connection with such issuance and with the requirements hereof and of the Plan.
The determination of the Administrator as to such compliance shall be final and
binding on the Grantee. The Grantee shall not be deemed to be the holder of, or
to have any of the rights of a holder with respect to, any shares of Stock
subject to the SAR&#146;s unless and until such SAR&#146;s shall have been exercised
pursuant to the terms hereof, the Company shall have issued and delivered the
shares to the Grantee or a nominee designated by the Grantee, and the Grantee&#146;s
name or the name of such Grantee&#146;s nominee shall have been entered as the
stockholder of record on the books of the Company. Thereupon, the Grantee shall
have full voting, dividend and other ownership rights with respect to such
shares of Stock.</font></p>

<h2 style="font-weight:normal;margin:0pt 0pt 12.0pt 18.0pt;page-break-after:avoid;text-indent:72.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">(c)&#160;&#160; The minimum number of SAR&#146;s that may be
exercised at any one time shall be 100, unless the number of SAR&#146;s being
exercised is the total number of SAR&#146;s subject to exercise under this Agreement
at the time.</font></h2>

<h2 style="font-weight:normal;margin:0pt 0pt 12.0pt 18.0pt;page-break-after:auto;text-indent:72.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">(d)&#160;&#160; Notwithstanding any other
provision hereof or of the Plan, no SAR shall be exercisable after the
Expiration Date thereof.</font></h2>

<h1 style="font-weight:normal;margin:0pt 0pt 12.0pt;page-break-after:auto;text-indent:36.0pt;"><font size="2" face="Times New Roman"><font style="font-size:10.0pt;">3.&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; </font><u>Termination
of Employment</u>. If the Grantee&#146;s employment with the Company or a Subsidiary
(as defined in the Plan) is terminated, the period within which to exercise the
SAR&#146;s may be subject to earlier termination as set forth below.</font></h1>

<h2 style="font-weight:normal;margin:0pt 0pt 12.0pt 18.0pt;page-break-after:auto;text-indent:72.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">(a)&#160;&#160; <u>Termination Due to Death</u>.
If the Grantee&#146;s employment terminates by reason of death, any SAR&#146;s held by
the Grantee shall become fully exercisable and may </font></h2>


 <p style="font-size:10.0pt;margin:24.0pt 0pt .0001pt;text-align:center;"><font face="Times New Roman">2</font></p> <br><hr size="3" width="100%" noshade color="#010101" align="center">

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<p style="margin:0pt 0pt 12.0pt 20.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">thereafter be exercised by the Grantee&#146;s legal
representative or legatee for a period of 12 months from the date of death or the
Expiration Date, if earlier.</font></p>

<h2 style="font-weight:normal;margin:0pt 0pt 12.0pt 18.0pt;page-break-after:auto;text-indent:72.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">(b)&#160;&#160; <u>Termination Due to
Disability</u>. If the Grantee&#146;s employment terminates by reason of disability
(as determined by the Administrator), any SAR&#146;s held by the Grantee shall
become fully exercisable and may thereafter be exercised by the Grantee for a
period of 12 months from the date of termination or until the Expiration Date, if
earlier. The death of the Grantee during the 12-month period provided in
this Section&nbsp;3(b)&nbsp;shall extend such period for another 12 months from
the date of death or until the Expiration Date, if earlier.</font></h2>

<h2 style="font-weight:normal;margin:0pt 0pt 12.0pt 18.0pt;page-break-after:auto;text-indent:72.0pt;"><font size="2" face="Times New Roman"><font style="font-size:10.0pt;">(c)&#160;&#160; </font><u>Termination for Cause</u>. If the Grantee&#146;s
employment terminates for Cause, any SAR&#146;s held by the Grantee shall terminate
immediately and be of no further force and effect. For purposes hereof, &#147;Cause&#148;
shall have the definition applied under the common law of the Commonwealth of
Massachusetts.</font></h2>

<h2 style="font-weight:normal;margin:0pt 0pt 12.0pt 18.0pt;page-break-after:auto;text-indent:72.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">(d)&#160;&#160; <u>Other Termination</u>. If
the Grantee&#146;s employment terminates for any reason other than death, disability
or Cause, and unless otherwise determined by the Administrator, any SAR&#146;s held
by the Grantee may be exercised, to the extent exercisable on the date of
termination, for a period of three months from the date of termination or until
the Expiration Date, if earlier. Any SAR that is not exercisable at such time
shall terminate immediately and be of no further force or effect.</font></h2>

<p style="margin:0pt 0pt 12.0pt;text-indent:36.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">The Administrator&#146;s determination of the reason for
termination of the Grantee&#146;s employment shall be conclusive and binding on the Grantee
and his or her representatives or legatees.</font></p>

<h2 style="font-weight:normal;margin:0pt 0pt 12.0pt 18.0pt;page-break-after:auto;text-indent:72.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">(e)&#160;&#160; If these SAR&#146;s are granted
in tandem with a Stock Option, then notwithstanding anything contained in this
Paragraph 3, the SAR&#146;s shall terminate and no longer be exercisable if and to
the extent that the related Stock Option is terminated or is no longer
exercisable.</font></h2>

<h1 style="font-weight:normal;margin:0pt 0pt 12.0pt;page-break-after:auto;text-indent:36.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">4.&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; <u>Incorporation of Plan</u>. Notwithstanding
anything herein to the contrary, these SAR&#146;s shall be subject to and governed
by all the terms and conditions of the Plan, including the powers of the
Administrator set forth in&#160; Section&nbsp;2(b)&nbsp;of
the Plan. Capitalized terms in this Agreement shall have the meaning specified
in the Plan, unless a different meaning is specified herein.</font></h1>

<h1 style="font-weight:normal;margin:0pt 0pt 12.0pt;page-break-after:auto;text-indent:36.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">5.&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; <u>Transferability</u>. This
Agreement is personal to the Grantee, is non-assignable and is not transferable
in any manner, by operation of law or otherwise, other than by will or the laws
of descent and distribution. These SAR&#146;s are exercisable, during the Grantee&#146;s
lifetime, only by the Grantee, and thereafter, only by the Grantee&#146;s legal
representative or legatee.</font></h1>

<h1 style="font-weight:normal;margin:0pt 0pt 12.0pt;page-break-after:auto;text-indent:36.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">6.&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; <u>Tax Withholding</u>. The Grantee
shall, not later than the date as of which the exercise of these SAR&#146;s becomes
a taxable event for Federal income tax purposes, pay to the Company or make
arrangements satisfactory to the Administrator for payment of any Federal,
state, and local taxes required by law to be withheld on account of such
taxable event. The Grantee may elect to have the minimum required tax
withholding obligation satisfied, in whole or in part, by (i)&nbsp;authorizing
the Company to withhold from shares of Stock to be issued, or (ii)&nbsp;</font></h1>


 <p style="font-size:10.0pt;margin:24.0pt 0pt .0001pt;text-align:center;"><font face="Times New Roman">3</font></p> <br><hr size="3" width="100%" noshade color="#010101" align="center">

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<p style="margin:0pt 0pt 12.0pt 20.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">transferring to the Company, a number of shares of
Stock with an aggregate Fair Market Value that would satisfy the withholding
amount due.</font></p>

<h1 style="font-weight:normal;margin:0pt 0pt 12.0pt;page-break-after:auto;text-indent:36.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">7.&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; <u>Miscellaneous</u>.</font></h1>

<h2 style="font-weight:normal;margin:0pt 0pt 12.0pt 18.0pt;page-break-after:auto;text-indent:72.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">(a)&#160;&#160; Notice hereunder shall be
given to the Company at its principal place of business, and shall be given to
the Grantee at the address set forth below, or in either case at such other
address as one party may subsequently furnish to the other party in writing.</font></h2>

<h2 style="font-weight:normal;margin:0pt 0pt 12.0pt 18.0pt;page-break-after:auto;text-indent:72.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">(b)&#160;&#160; This SAR Agreement does not
confer upon the Grantee any rights with respect to continuance of employment by
the Company or any Subsidiary.</font></h2>

<h2 style="font-weight:normal;margin:0pt 0pt 12.0pt 18.0pt;page-break-after:auto;text-indent:72.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">(c)&#160;&#160; Pursuant to Section&nbsp;15 of
the Plan, the Administrator may at any time amend or cancel any outstanding
portion of these SAR&#146;s, but no such action may be taken which adversely affects
the Grantee&#146;s rights under this Agreement without the Grantee&#146;s consent.</font></h2>

<table border="0" cellspacing="0" cellpadding="0" width="100%" style="border-collapse:collapse;width:100.0%;">
 <tr>
  <td width="54%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:54.16%;">
  <p style="font-size:10.0pt;margin:0pt 0pt .0001pt;"></p>
  </td>
  <td width="5%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:5.96%;">
  <p style="margin:0pt 0pt .0001pt;"><b><font size="2" face="Times New Roman" style="font-size:1.0pt;font-weight:bold;">&nbsp;</font></b></p>
  </td>
  <td width="39%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:39.9%;">
  <p style="margin:0pt 0pt .0001pt;"><b><font size="2" face="Times New Roman" style="font-size:10.0pt;font-weight:bold;">ANIKA THERAPEUTICS, INC.</font></b></p>
  </td>
 </tr>
 <tr>
  <td width="54%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:54.16%;">
  <p style="margin:0pt 0pt .0001pt;"><b><font size="2" face="Times New Roman" style="font-size:10.0pt;font-weight:bold;">&nbsp;</font></b></p>
  </td>
  <td width="5%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:5.96%;">
  <p style="margin:0pt 0pt .0001pt;"><b><font size="2" face="Times New Roman" style="font-size:10.0pt;font-weight:bold;">&nbsp;</font></b></p>
  </td>
  <td width="39%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:39.9%;">
  <p style="margin:0pt 0pt .0001pt;"><b><font size="2" face="Times New Roman" style="font-size:10.0pt;font-weight:bold;">&nbsp;</font></b></p>
  </td>
 </tr>
 <tr>
  <td width="54%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:54.16%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="5%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:5.96%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">By:</font></p>
  </td>
  <td width="39%" valign="top" style="border:none;border-bottom:solid windowtext 1.0pt;padding:0pt .7pt 0pt 0pt;width:39.9%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr>
  <td width="54%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:54.16%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="5%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:5.96%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="39%" valign="top" style="border:none;padding:0pt .7pt 0pt 0pt;width:39.9%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">Name:</font></p>
  </td>
 </tr>
 <tr>
  <td width="54%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:54.16%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="5%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:5.96%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="39%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:39.9%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">Title:</font></p>
  </td>
 </tr>
</table>

<p style="line-height:1.0pt;margin:0pt 0pt 12.0pt;"><font size="1" face="Times New Roman">&nbsp;</font></p>

<p style="margin:0pt 0pt 12.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">The foregoing Agreement is hereby accepted and the
terms and conditions thereof hereby agreed to by the undersigned.</font></p>

<table border="0" cellspacing="0" cellpadding="0" width="100%" style="border-collapse:collapse;font-family:Times New Roman;width:100.0%;">
 <tr>
  <td width="6%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:6.96%;">
  <p style="font-size:10.0pt;margin:0pt 0pt .0001pt;">Dated:</p>
  </td>
  <td width="33%" valign="top" style="border:none;border-bottom:solid windowtext 1.0pt;padding:0pt .7pt 0pt 0pt;width:33.8%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="12%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:12.92%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="41%" valign="top" style="border:none;border-bottom:solid windowtext 1.0pt;padding:0pt .7pt 0pt 0pt;width:41.62%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="4%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:4.7%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr>
  <td width="6%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:6.96%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="33%" valign="top" style="border:none;padding:0pt .7pt 0pt 0pt;width:33.8%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="12%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:12.92%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="41%" valign="top" style="border:none;padding:0pt .7pt 0pt 0pt;width:41.62%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="4%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:4.7%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr>
  <td width="6%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:6.96%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="33%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:33.8%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="12%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:12.92%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="41%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:41.62%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">Grantee&#146;s Signature</font></p>
  </td>
  <td width="4%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:4.7%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr>
  <td width="6%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:6.96%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="33%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:33.8%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="12%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:12.92%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="41%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:41.62%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="4%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:4.7%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr>
  <td width="6%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:6.96%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="33%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:33.8%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="12%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:12.92%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
  <td width="41%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:41.62%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">Grantee&#146;s name and address:</font></p>
  </td>
  <td width="4%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:4.7%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:1.0pt;">&nbsp;</font></p>
  </td>
 </tr>
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  <td width="6%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:6.96%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="33%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:33.8%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="12%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:12.92%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="41%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:41.62%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="4%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:4.7%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr>
  <td width="6%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:6.96%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="33%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:33.8%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="12%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:12.92%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="41%" valign="top" style="border:none;border-bottom:solid windowtext 1.0pt;padding:0pt .7pt 0pt 0pt;width:41.62%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="4%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:4.7%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr>
  <td width="6%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:6.96%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="33%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:33.8%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="12%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:12.92%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="41%" valign="top" style="border:none;padding:0pt .7pt 0pt 0pt;width:41.62%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="4%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:4.7%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr>
  <td width="6%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:6.96%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="33%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:33.8%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="12%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:12.92%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="41%" valign="top" style="border:none;border-bottom:solid windowtext 1.0pt;padding:0pt .7pt 0pt 0pt;width:41.62%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="4%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:4.7%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr>
  <td width="6%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:6.96%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="33%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:33.8%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="12%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:12.92%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="41%" valign="top" style="border:none;padding:0pt .7pt 0pt 0pt;width:41.62%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="4%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:4.7%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
 </tr>
 <tr>
  <td width="6%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:6.96%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="33%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:33.8%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="12%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:12.92%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="41%" valign="top" style="border:none;border-bottom:solid windowtext 1.0pt;padding:0pt .7pt 0pt 0pt;width:41.62%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
  <td width="4%" valign="top" style="padding:0pt .7pt 0pt 0pt;width:4.7%;">
  <p style="margin:0pt 0pt .0001pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>
  </td>
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</table>

<p style="margin:0pt 0pt .0001pt 252.0pt;"><font size="2" face="Times New Roman" style="font-size:10.0pt;">&nbsp;</font></p>


 <p style="font-size:10.0pt;margin:24.0pt 0pt .0001pt;text-align:center;"><font face="Times New Roman">4</font></p>
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