PROXY The undersigned shareholder of ________________ authorizes __________ to act as his/her proxy and to represent and vote his/her shares at a(n) __________ meeting of shareholders to be held at __________, state of __________, on __________, 20___ at ____:____ __.M. Dated: _________________ Signature of Shareholder: ___________________________ Printed Name of Shareholder: ________________________ Please return proxy by __________, 20___ to: Name: _______________________________________________ Title: ______________________________________________ Corporation: ________________________________________ Address: ____________________________________________ City, State, Zip: ___________________________________ Fax: ________________________________________________ Phone: ______________________________________________
Proxy
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