Today's Date: _________________________

Member who is authorizing the Proxy (i.e., person filling out this form)

Name: ______________________________

Building/Apartment: _________ / _________

Telephone: ____________________ Best Time to Call: ____________

E-Mail Address: _____________________________ (only for proxies via E-mail)

Duration (maximum 6 months): _________________

Signature: __________________________________________

Other Member who will Serve as Proxy (i.e., person to act on your behalf)

Name: ______________________________

Building/Apartment: _________ / _________

Telephone: ____________________ Best Time to Call: ____________