I, ____________________, a stockholder of record of ____________________ (the "Corporation") do hereby constitute and appoint as my lawful attorney, and agent, ____________________ for a period expiring on ____________________, to represent me at any and all stockholder meetings of the corporation and at any adjournment thereof, to act for and in the name, place and stead of the undersigned on all matters and things which may be presented for action or consideration at such meetings, giving and granting unto said attorney full power in all respects that I could exercise if present in person.
Date: ___________________ ____________________
____________________
Witness Name:____________________
Notary's Acknowledgment
State of __________________ )
) ss
County of_________________ )
On this _______________________, before me personally appeared ____________________, to me known to be the person described in and who executed the foregoing instrument and acknowledged to me that ____________________ executed the same as said person's free act and deed.
_________________________________
Notary Public