PROXY

BE IT KNOWN, that I,  __________, the undersigned Shareholder of 

__________, a __________ corporation, hereby constitute and appoint 

__________ as my true and lawful attorney and agent for me and in my 

name, place and stead, to vote as my proxy at the Meeting of the 

Shareholders of the said corporation, to be held on __________ or any 

adjournment thereof, for the transaction of any business which may 

legally come before the meeting, and for me and in my name, to act as 

fully as I could do if personally present; and I herewith revoke any 

other proxy heretofore given. 

WITNESS my hand and seal this _____ day of __________, 19___

Signed: ____________________

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