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Revocable Proxy
REVOCABLE PROXY
For payment of one dollar ($1) and other compensation, I hereby confer upon a proxy to vote [Number of shares] shares of [Name of Corporation], hereinafter "Corporation", in my stead and on my behalf at the Corporation shareholders' meeting to be held on [Date of meeting], and at all subsequent regular and special meetings of shareholders of the Corporation. Said person shall have all the power to vote and attend meetings as I currently enjoy. Until this proxy is revoked, which act may be executed without notice, I shall not vote the shares represented.
Signed Date