I, _Stockholder_, a stockholder of record of __Name of Corporation__ (hereinafter the "Corporation") do hereby constitute and appoint as my lawful attorney, and agent, [Proxy's Name] for a period expiring on ___End of Proxy Term___, 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.
State of __________________ )
County of_________________ )
On this _______________________, before me personally appeared __Stockholder__, to me known to be the person described in and who executed the foregoing instrument and acknowledged to me that __Stockholder__ executed the same as said person's free act and deed.
My Commission Expires on: __________________, 200_
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