Revocable Proxy [COMPANY NAME]

The undersigned, as record holder of the securities of [Name of corporation] described below, hereby revokes any previous proxies and appoints [Name] as the undersigned’s proxy to attend all shareholders’ meetings and to vote, execute consents, and otherwise represent those shares in the same manner and with the same effect as if the undersigned were personally present at any such meeting or voting such securities or personally acting on any matters submitted to shareholders for approval or consent.

1.The proxy holder will have the full power of substitution and revocation.

2.This proxy is made pursuant to an agreement of [DESCRIBE], dated [Date].

3.This proxy is revocable at any time, and unless revoked, shall terminate on [Date].

BE IT KNOWN, that the undersigned, being the owner of [Number] shares of voting stock of [Corporation name], do hereby grant to [Name], a proxy to vote on behalf of the undersigned [Number] shares of said stock at any future meeting of the stockholders of the Corporation; and said proxy holder is entitled to attend said meetings on my behalf or vote said shares through mail proxy.

During the pendency of this proxy, all rights to vote said shares shall be held by the proxy holder and shall not be voted by the undersigned, provided the undersigned may revoke this proxy at any time.

THIS PROXY SHALL BE SIGNED EXACTLY AS THE SHAREHOLDER’S NAME APPEARS ON HIS STOCK CERTIFICATE. JOINT SHAREHOLDERS MUST EACH SIGN THIS PROXY. IF SIGNED BY AN ATTORNEY IN FACT, THE POWER OF ATTORNEY MUST BE ATTACHED.

[Signature]

[Printed name as appears on stock certificate]

Securities Information:

Certificate No.:

Number of Shares:

Class of Shares: