PROXY
I do hereby constitute, make, and appoint ____________________________________ ____________________________________________________________________ (name and address) my true and lawful attorney with full power of substitution, for me and in my name, place and stead, to vote at the ________________________________ ____________________________________ (location) or at any adjournment thereof or at any special meeting of the ____________________________________ (corporation) thereafter, during the period of twelve months from the date hereof, for the election of directors and for the transaction of such other business as may properly come before said meeting, according to the number of votes I would be entitled to cast if personally present.
Witness my hand this ______________ day of ____________________________
________________________________________ (seal)
________________________________________ (seal)
Signed in the Presence of:
___________________________________________