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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: |
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