DIY Legal Forms

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Model Proxy

1. Introduction. I, [name], residing at [address], own [number] shares of the Common Stock of [name of corporation].

2. Appointment of Proxy. I appoint [name], with offices at [address], attorney and proxy for me, to vote on all my stock in Corporation. [Name of holder of proxy], as proxy, is entitled to vote the number of votes that I would be entitled to vote if I were present at the meeting. I place no limitation on [name]'s voting power or on the matters in which [name] may vote.

3. Effective Date of Appointment. This appointment of [name] as proxy shall take effect on [date] and shall remain in effect until [date] unless I revoke the proxy before that time. All other proxies made by me are revoked.

[signature]

[dated]

Witnessed by: [signature]

*** If Required By State Law ***

This Section for Notary:

ACKNOWLEDGMENT

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.

Signature ________
Notary

My commission expires: _____

(Seal)