BANKING & FINANCIAL ACCOUNT REPRESENTATION PROXY
================================================================

Effective Date: ________________________________________________________
Place: _________________________________________________________________

================================================================

1. Parties
----------

This document is made on ____________________ (____________________) by:

Account Holder
Individual
Full Legal Name: _______________________________________________________
SSN / ID: ______________________________________________________________
Doc Series: ____________________________________________________________
Address: _______________________________________________________________
         _______________________________________________________________

In favor of:

Authorized Representative
Individual
Full Legal Name: _______________________________________________________
SSN / ID: ______________________________________________________________
Doc Series: ____________________________________________________________
Address: _______________________________________________________________
         _______________________________________________________________

2. SUBJECT-MATTER SCHEDULE & SPECIFICATIONS
-------------------------------------------

Bank Name & Branch: ____________________________________________________
Account Number(s): _____________________________________________________
Permitted Transactions: ________________________________________________
Transaction Limits: ____________________________________________________
Authorization Valid Until: _____________________________________________

3. EXECUTION & SIGNATURES
-------------------------

Account Holder

Signature: _____________________________________________________________

Full Legal Name: _______________________________________________________
Date: __________________________________________________________________