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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.
Witnessed by: [signature]
*** 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: _____