GENERAL PROXY The undersigned of ______________, being a stockholder of ______________________ Inc., does hereby constitute and appoint as the lawful attorney, agent and proxy of the undersigned the following named person:__________________ for a period of ______________ from the date hereof, to represent the undersigned at any and all stockholders meetings of ____________________ Inc., and at any adjournment thereof, within ____________ from the date hereof, to act for and in the name, place and stead of the undersigned on all matters and things which may be presented for action or consideration at such meetings, giving and granting unto said attorney and proxy as full power in all respects as the undersigned could exercise if present in person. The undersigned hereby ratifies all that his attorney and proxy may or shall lawfully do in voting at any such meetings, or at any adjournment or adjournments thereof, within the period of time specified, in respect of all matters, proposals and questions that may properly come before the stockholders for consideration and action. Dated: ________________________________ __________________________ Witness Form 618