BE IT DNOWN, that I,__(1)__,the undersigned Shareholder of__(2)__,a__
(3)__corporation, hereby constitute and appoint__(4)__as my true and lawful attorney and agent for me and in my name, place and stead, to vote as my proxy at the Meeting of the Shareholders of the said corporation, to be held on__(5)__or any adjournment thereof, for the transaction of any business which may legally come before the meeting, and for me and in my name, to act as fully as I could do if personally present; and I herewith revoke any other proxy heretofore given.
WITNESS my hand and seal this__(6)__day of__(7)__,20__(8)__.
