PROXY

KNOW ALL MEN BY THESE PRESENTS:

That the undersigned, a stockholder of ____________________ CORPORATION, do hereby name, constitute and appoint:

Mr. ________________________, or in his absence

Mr. ________________________, or in his absence

the Chairman of the shareholders' meeting, as his/her/its true and lawful attorney-in-fact for it and in his/her/its name, place and stead, to do and perform the following acts and things, to wit:

To attend, be present and represent the undersigned at any and all meetings of the stockholders of ________________________ including any adjournment or postponement thereof; take part in the deliberations thereon; vote any and all shares that the undersigned now owns or may hereafter own in said Corporation in any matter, motion, resolution that may be taken up in said meeting/s in such manner as his/her/its aforesaid attorney-in-fact shall deem acceptable in the premises.

HEREBY GIVING AND GRANTING unto the said attorney-in-fact full power and authority to do and perform any and every act requisite or proper to be done in or about the premises, as fully to all intents as the undersigned might or could lawfully do if personally present and acting in person; and hereby ratifying and confirming all that said attorney-in-fact shall lawfully do or cause to be done by virtue hereof.

Executed at ______________________, on _____________