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For payment of one dollar $------, I hereby bestow upon ____________________ a proxy to vote ______________________ (--) shares of stock of ______________________ (hereinafter "Corporation") on my behalf at the shareholder's meeting of said Corporation, which will be held __________________, 20 __. The proxy is conferred in consideration of the following conditions:
Said person shall have all the power to vote and attend the aforesaid meeting as I currently enjoy.
This proxy, which may not be revoked by myself, nor my heirs or assigns, shall not last for a period beyond the above noted shareholder's meeting, or any extension thereof.
*** If Required By State Law ***
This Section for Notary:
State of _________
County of ________ [COUNTY]
On [DATE] before me, [NAME OF NOTARY], notary, personally appeared [NAME OF PERSON(S) INVOLVED], 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.
My commission expires: _____