_____________________________ (Date)


______________________________ (Name of warehouseman)


______________________________ (Address)


The undersigned hereby acknowledges receipt from ___________________________ (warehouseman), of ____________________________________________ (address), _________________ (city), _______________ County, __________ (state), warehouse receipt no. __________________, which covers the property and goods stored by me in warehouse number __________ at _________________________________ (address), ________________ (city), ________________ County, ____________ (state), on __________ (date).


(R) I have checked the list of goods on such receipt and read the terms and conditions on the reverse side of the receipt, and hereby acknowledge that the description of the goods on the receipt is accurate and correct.


__________ (Warehouseman) is hereby authorized to honor delivery orders signed by me or any of the following authorized persons for all or any part of the property and goods stored under the above-mentioned receipt. The signatures of the authorized persons are as follows:


1Authorized Parties’ Signatures:







__________________________________________   ____________________

Signature of depositor                                                      Date