SPECIAL POWER OF ATTORNEY

The undersigned, (ENTER FULL NAME, PASSPORT NUMBER, MARITAL STATUS, OCCUPATION, FULL DOMICILE), in my capacity as (ENTER POSITION IN THE COMPANY) and therefore as legal representative of (ENTER FULL COMPANY NAME), a company organized and existing under the laws of (ENTER STATE AND COUNTRY OF INCORPORATION), company domiciled at (ENTER FULL DOMICILE OF THE COMPANY), (ENTER REGISTRATION INFORMATION FOR THE COMPANY, IF ANY), grant Henry Lang Wien, of legal age, married once, attorney at law, Costa Rican identification number one -six nine four - six three two, resident of Santa Ana, a SPECIAL POWER OF ATTORNEY for obtaining from the corresponding offices and national authorities in Costa Rica, the registration of the trademark (ENTER NAME OF TRADEMARK TO BE FILED) in international class (ENTER INTERNATIONAL CLASS), for which purposes he is granted capacities to perform before such authorities all steps that are necessary for the indicated purposes; to sign and file petitions, declarations and claims; to make descriptions, amendments, oppositions and appeals; to request cancellations and annulations; to accept, perform and/or authorize transfers and assignments; to assign; to receive assignments; to make sworn declarations; to pay all taxes and fees; to receive documents and values by giving the corresponding waiver; to fulfill any other requirements and to take any other measures that they consider appropriate for the protection of our interests; he is also granted the capacity to protect and defend the above mentioned trademarks by filing oppositions, cancellations and all other actions needed for such purpose against the registration or use of identical or similar marks. I hereby declare from now on valid and good everything that such holder of power of attorney may do in benefit of the above mentioned company, also giving him the capacities to substitute its power of attorney and revoke substitutions, maintaining its appointment. I also authorize Mr. Henry Lang Wien to appoint any notary public of his choice, including himself, to protocolize literally all pertaining parts of this document. I sign in the city of (ENTER CITY, STATE, COUNTRY OF SIGNATURE), on the day (ENTER DAY) of (ENTER MONTH) of (ENTER YEAR).
(ENTER FULL NAME)
___________
Legal Representative
(ENTER FULL NAME OF COMPANY)

Declared before me on the day (ENTER DAY OF NOTARIZATION) of (ENTER MONTH OF NOTARIZATION) of (ENTER YEAR OF NOTARIZATION).
(ENTER FULL NAME OF NOTARY)
______________________
Notary Public