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For payment of one $------ (Dollars) and other compensation, I, the Undersigned, hereby confer upon ___________ (Name) a proxy to vote _________ (___) shares of _________ (hereinafter referred to as "Corporation") in place of me, and on my behalf at the Corporation shareholders meeting to be held on the ________ day of ________, 20 __, 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.
ACKNOWLEDGEMENT BY NOTARY PUBLIC
State of ________)
On ________, before me, ________, Notary Public, personally appeared ________, who proved to me on the basis of satisfactory evidence to be the person(s) whose names(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 signatures on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under the PENALTY OF PERJURY under the laws of the State of _________ that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Name of Notary
My Commission Expires