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Proxy To Vote Shares
PROXY TO VOTE SHARES
The undersigned, [Shareholder's Name], is the holder of [Number of Shares] shares of the common stock of [Corporation's Name], hereby authorizes [Appointee's Name] to vote those shares at the meeting of shareholders of the said Corporation to be held on the [Date] at [Time], or any adjournment thereto, at [Address] in the City of [Name of City]. Under this authority, [Appointee's Name] shall have the right to vote for the election of directors and on any other matter as may properly be raised at the meeting, all with the same force and effect as if I were voting said shares personally.
Date: [Date]
Time: [Time]
[Jurisdiction]
STATE OF [State]
COUNTY OF [County]
On [Date] before me, [Person's Name] personally appeared and proved to me on the basis of satisfactory evidence to be the [person(s)] whose name(s) [is/are] subscribed to the within instrument and acknowledged to me that [he/she/they] executed the same in [his/her/their] authorized [capacity(ies)], and that by the [signature(s)] on the instrument the [person(s)], or the entity upon behalf of which the [person(s)] acted, executed the instrument.
WITNESS my hand and official seal.
Signatures
[Identification Produced]
Seal