I, [NAME], a shareholder of [CORPORATION'S NAME], a [STATE] corporation ("Corporation"), do hereby constitute and appoint [PROXY #1] and [PROXY #2], or the survivor of them, to be my proxy agent, with full power of substitution, for a period of [DESCRIBE] from this date, to vote as my proxy all of my shares of common stock in the Corporation with respect to all matters submitted to the shareholders at all regular and general meetings of the shareholders, or any adjournments thereof, and in all consents to any actions taken without a meeting, which may occur during said period. This appointment shall continue from this date until [DATE], and during said period, my proxy shall have all of the power that I would possess with respect to the voting my shares and the granting of my consent. I hereby ratify and confirm all acts that my proxy shall do or cause to be done by virtue of and within the limitations set forth in this proxy.

I hereby revoke all proxies previously given by me with respect to all my shares of common stock in the Corporation.

IN WITNESS WHEREOF, I have executed this proxy on [DATE].

________________________

Shareholder

________________________

Print Name