I, [NAME] ________________________, of ____________________________,
hereby appoint [NAME] ____________________, of ______________________,
as my attorney in fact to act in my capacity to do every act that I may legally do through
an attorney in fact. This power shall be in full force and effect on the date below written
and shall remain in full force and effect until [DATE] ___________________
or unless specifically extended or rescinded earlier by either party.
Dated __________, 20____.
By: _________________________
STATE OF _________________COUNTY OF ________________
BEFORE ME, the undersigned authority, on this ____________ day of _____________,
20_____, personally appeared __________ to me well known to be the person described
in and who signed the Foregoing, and acknowledged to me that he executed the same
freely and voluntarily for the uses and purposes therein expressed.
WITNESS my hand and official seal the date aforesaid.
NOTARY PUBLIC
My Commission Expires:
