BE IT KNOWN that the undersigned, being the owner of_______ shares of voting stock of________________________, (the "Corporation"), do hereby grant to ______________________, a proxy to vote on behalf of the undersigned ______ shares of the said stock at any future meeting of the stockholders of the Corporation, and the said proxy holder is entitled to attend any said meetings on my behalf or vote the said shares through mail proxy.
During the pendency of this proxy, all rights to vote the said shares shall be held by the proxy holder and shall not be voted by the undersigned, provided the undersigned may revoke this proxy at any time.
Dated this_____ day of_________________, 201(x).
IN WITNESS WHEREOF I have hereunto set my hand and seal on the day and year first above written.
in the presence of: