PROXY

BE IT KNOWN, that I, ________________, the undersigned Shareholder of _______________, a __________ corporation, hereby constitute and appoint ___________________ 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 _______________ 
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 __ day of _______, 20__.

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