POWER OF ATTORNEY The undersigned, of _____________________, have made, constituted and appointed, and do make, constitute and appoint, _____________________ of ___________________________ my true and lawful attorney in fact, for me and in my name and stead, and to my use, to _________________________ hereby giving to my attorney in fact, full authority and power to do everything whatsoever requisite or necessary to be done, as fully as I could or might do if personally present, with full power of substitution and revocation, hereby confirming and ratifying all that my said attorney in fact shall lawfully do or cause to be done, hereunder. Dated: ___________________________ __________________________ Witness Form 612