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PROXY

BE IT KNOWN, that I, __________, the undersigned Shareholder of __________, a __________ corporation, hereby constitute and appoint __________ as my true and lawful attorney and agent for me and in my name, place and stead, to vote as my proxy at the Meeting of the Shareholders of the said corporation, to be held on __________ or any adjournment thereof, for the transaction of any business which may legally come before the meeting, and for me and in my name, to act as fully as I could do if personally present; and I herewith revoke any other proxy heretofore given.

WITNESS my hand and seal this _____ day of __________, 20___

Signed: ____________________

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