SEC Filings

10-12G/A
AMSURG CORP filed this Form 10-12G/A on 05/21/1997
Entire Document
 
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                                 AMSURG CORP

     The shares represented by this certificate shall automatically convert
into an equal number of shares of Class A common stock, no par value, upon any
sale, assignment or gift or other disposition or transfer other than: (1) a
pledge or hypothecation or other granting of an interest in the shares as 
security for a loan so long as the shareholder retains ownership of the shares
or (2) a transfer to or from
 street name or a change in street name if in each
such case beneficial ownership of the shares subject to transfer remains the
same.

     The Company will furnish the shareholder information regarding the
designations, relative rights, preferences, and limitations applicable to each
class and series and the variations in rights, preferences, and limitations for
each class and series of stock issued by the Company (and the authority of the
board of directors to determine variations for future classes or series) upon
request in writing and without charge.

     The following abbreviations, when used in the inscription on the face of
this certificate, shall be construed as though they are written out in full
according to applicable laws or regulations:

     TEN COM -- as tenants in common
     TEN ENT -- as tenants by the entireties
     JT TEN  -- as joint tenants with right of survivorship and not as tenants
                in common

     UNIF GIFT MIN ACT -- ____________________ Custodian _______________________
                                  (Cust)                          (Minor)
                          under Uniform Gifts to Minors Act

                          ______________________________________________________
                                                (State)


   Additional abbreviations may also be used though not in the above list.


       For value received, __________________________________ hereby sell,
assign and transfer unto

          PLEASE INSERT SOCIAL SECURITY OR OTHER
              IDENTIFYING NUMBER OF ASSIGNEE

       ___________________________________________


       _________________________________________________________________________
       PLEASE PRINT OR TYPEWRITE NAME AND ADDRESS INCLUDING ZIP CODE OF ASSIGNEE

       _________________________________________________________________________

       _________________________________________________________________________
   
       __________________________________________________________________ Shares
  
       of the capital stock represented by the within Certificate, and do hereby
       irrevocably constitute and appoint

       _____________________________________________________________ Attorney to
       transfer the said stock on the books of the within-named Corporation with
       full power of substitution in the premises.

       Dated ___________________________________




                                    ____________________________________________
                                    NOTICE: THE SIGNATURE TO THIS ASSIGNMENT 
                                    MUST CORRESPOND WITH THE NAME AS WRITTEN
                                    UPON THE FACE OF THE CERTIFICATE IN EVERY 
                                    PARTICULAR WITHOUT ALTERATION OR ENLARGEMENT
                                    OR ANY CHANGE WHATEVER.




SIGNATURE(S) GUARANTEED: _______________________________________________________
                         THE SIGNATURE(S) SHOULD BE GUARANTEED BY AN ELIGIBLE 
                         FINANCIAL INSTITUTION (BANK, STOCKBROKERS, SAVINGS 
                         AND LOAN ASSOCIATIONS AND CREDIT UNIONS) WITH
                         MEMBERSHIP IN AN APPROVED SIGNATURE GUARANTEE MEDALLION
                         PROGRAM, PURSUANT TO SEC RULE 17Ad-15.