PROXY FORM FOR ISLAND HOUSE MEMBERS


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: ____________