I, _______________________, a stockholder of record of ____________________                         (“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:

 

__________________

Shareholder

 

Witness Signature: __________________________

Print Name

 

Notary’s Acknowledgment

State of:

County of:

On this   _________________ (Date), before me personally appeared ________

(Name of Shareholder), known to me as the person described in and who executed the foregoing instrument and acknowledged to me that he/she executed the same as said person’s free act and deed.

 

 

______________________

Notary Public

Commission Expires:

 

 

Proxy

Review List

 

This review list is provided to inform you about the document in question and assist you in its preparation.

 

 

 

1.     A Proxy must be signed by the Stockholder with their name signed exactly as written on their share certificate or certificates.  If the stock is jointly owned, the Proxy must be signed by all Stockholders with their exact names.  The signatures should be notarized because, in important matters, they may be challenged.

 

2.    While most states do not require the signing of a Proxy to be witnessed or notarized, taking these steps provides additional assurance that the Proxy will withstand challenges to its validity.

 

3.  The original signed proxy should be provided to the corporate secretary prior to the meeting or, if not possible, by the proxy at the meeting.  The Stockholder should keep a copy for his or her files and provide the Proxy a copy.

 

4.    Be sure to instruct the proxy as to how the shares should be voted.

 

5.    The Proxy is effective until the end of term date specified on the document.

 

6.    The Proxy may be terminated prior to its official termination date by prior written notice sent to the corporation in question.

 

________________________________________________________________________________

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