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____________________________________
NAME
Principal
Conforme:
____________________________
NAME
Attorney-in-Fact
SIGNED IN THE PRESENCE OF:
____________________________
Signature over printed name
____________________________
Signature over printed name
ACKNOWLEDGMENT:
known to me and to me known as the same persons who executed the foregoing Special Power
of Attorney consisting of ____________ (__) pages, including this page, and acknowledged to
me that the same is their free and voluntary act and deed, and that they and their witnesses
have freely and voluntarily affixed their signatures to this instrument.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my notarial seal on
the day and at the place written above.
NOTARY PUBLIC
Doc. No. ___
Page No. ___
Book No.___
Series of 2015