Fill and Sign the Member Nonprofit Form

Proxy of Member of Nonprofit Corporation The undersigned, being a member of ____________________ (Name of Corporation) , a ___________________ (name of state) nonprofit corporation, appoints _________________ (Name) , whose address is _______________________________________________________ _____________________________________ (street address, city, state, zip code) , to be my lawful proxy to attend and represent me at any meeting of the Members of the corporation, and at any adjournment of a meeting, and to vote and act for me on any matter that may come before the meeting and take any other action which I could presumably take if present at the meeting. This proxy shall remain in effect for ____ months from the date of this proxy unless earlier revoked by me or replaced by substitution. Witness my signature this the _____ day of _____________, 20_____. ___________________________________ (Printed Name of Member) ___________________________________ (Signature of Member) (Acknowledgment form may vary by state) State of _____________________ County of ___________________ Personally appeared before me, the undersigned authority in and for the said County and State, on this _______________ (date) , within my jurisdic tion, the within-named ______________________ (Name of Member) , who acknowledged that he executed the above and foregoing instrument. ________________________________ NOTARY PUBLIC My Commission Expires: ____________________