STOCKHOLDER'S PROXY KNOWN ALL MEN BY THESE PRESENTS, that ________________________ the undersigned, being the owner(s) of ________________________ (________) shares of ____________________________(common/preferred) Stock of ____________________, a Corporation, do hereby constitute and appoint as my (our) true and lawful Attorney-In-Fact: ___________________________________ whose address is ________________________ in the City of ___________________, State of _________________, such individual being empowered to vote upon the Stock owned by me (us), or standing in my (our) name, as my (our) PROXY at the Meeting of the Stockholders of said Corporation for and in my (our) name, place and stead. Such Meeting of the Stockholders of said Corporation will be held at ________________________________ in the City of ______________, State of _____________, on _________________ (date), at the hour of _______ o'clock _____.m., or such other day and time as the meeting may be thereafter held by adjournment or otherwise according the number of votes now, or may then be entitled to be voted, hereby granting said Attorney-In-Fact full and complete power and authority to act for me (us) and in my (our) name at the meeting or meetings in the transaction of such other business as may come before the meeting. Said Attorney-In-Fact is empowered to take action as fully as I (we) could do if personally present, with full power of substitution and revocation. My/our signatures below hereby ratifies and confirms all that my (our) said Attorney-In-Fact or a designated substitute may do in my (our) place, name and stead. Unless revoked by written notice filed with the Secretary of said Corporation, this Proxy will continue in full force until _______________ (date). Proxy may be revoked at any time by notice of revocation filed with the Secretary of said Corporation. IN WITNESS WHEREOF, I (WE) have hereunto set my(our) hand(s) and seal on this ___________ day of___________ (month), ______ (year).
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State of______________________ County of____________________ On ______________ (date) before me, ____________________, appeared personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/ they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. WITNESS my hand and official seal.
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