BALLOT

XYZ Company, Inc.

200__ Annual Shareholders’ Meeting

Ballot for the Election of Board of Directors

Write the number of shares for each candidate up to the total number of shares you own and are entitled to vote for up to three candidates (your total shares are voted three times, or may be aggregated (multiplied by three) and placed on a single candidate):

Three Directors will be elected based on the total number of shares voted for each Director.  If you have questions please contact the corporate Secretary prior to voting.

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Signature

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Name

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Date

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Current Phone

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Current email

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Current Address

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