Revocation of Proxy [COMPANY NAME]
The undersigned, as owner of the securities of [Name of corporation] described below, hereby revokes any and all proxies and substitutions of proxies, including the proxy executed on [Date], naming [Name] as proxy, and further revokes any and all authority heretofore given to any person or persons to attend meetings, vote, consent, or otherwise act on behalf of the undersigned in any manner whatsoever with respect to such securities.
[Printed name as on stock certificate]
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