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Annual Meeting Proxy Form

Health declaration

Please fill out the following form.

Date of birth
Month
Day
Year
Have you been hospitalized in the last 12 months?
No
Yes
Are you suffering from a medical condition, illness or injury?
No
Yes

FILLMORE HISTORICAL MUSEUM

REVOCABLE PROXY
Annual Meeting, February 28, 2026

​

NAME:_________________________________________________________________

I appoint a majority of the board of directors in office from time to time of the Fillmore Historical
Museum of Fillmore, California, to cast my vote at any Annual or special meeting of the membership of said
organization.
This proxy shall remain in effect and continue in force from the date hereof or until this proxy is
cancelled or revoked in writing or a proxy duly executed by me and bearing a later date is filed with the
Secretary of the organization, or if I attend the Annual or Special Meeting of the organization in person.

Dated this _____________day of ___________________, 20________________

___________________________________________________________________

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