Stock Purchase Authorization
with Proxy Voting Rights
1. Purchaser Information
Full Name
Address
Contact Information
2. Stock Details
Company Name
Type of Stock
Number of Shares
Purchase Price per Share
Total Purchase Price
Date of Purchase
3. Proxy Voting Authorization
Name of Proxy
Relationship to Purchaser
Scope of Proxy Authority
4. Additional Terms and Comments
5. Signatures
Purchaser Signature
Date
Proxy Signature
Date