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For payment of $------ and other compensation, I the undersigned, hereby confer upon [Name] a proxy to vote (--) shares of [Corporation] (hereinafter referred to as "Corporation") in my stead and on my behalf at the Corporation shareholders meeting to be held on [Date], and at all subsequent regular and special meetings of shareholders of the Corporation.
Said person shall have all the power to vote and attend meetings as I currently enjoy. Until this proxy is revoked, which act may be executed without notice, I shall not vote the shares represented.
[Name], of Undersigned
*** 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: _____