That I, ______, of legal age, single/married and a resident of ____, do hereby appoint, name and constitute _______, of legal age, single/married and a resident of ____, to be my true and lawful attorney-in-fact, to manage and conduct all my affairs, and for that purpose in my name and on my behalf to do and executed all or any of the following acts, deeds and things, to wit:

           (enumerate all acts and things the attorney-in-fact envisions for him to perform)

           In general, to do all other acts, deeds, matters and things whatsoever in or about my estate, property and affairs, or to concur with persons jointly interested with my self therein doing all acts, deeds, matters and things herein, either particularly or generally described, as fully and effectually to all intents and purposes as I could do in my own proper person if personally present.

           HEREBY GIVING AND GRANTING unto my said attorney full power and authority whatsoever requisite or necessary or proper to be done in or about the premises, as fully to all intents and purposes as I might or could lawfully do if personally present, (with power of substitution and revocation), and hereby ratifying and confirming all that my said attorney shall do or cause to be done under and by virtue of these presents.

           IN WITNESS WHEREOF, I have affixed my signature on this___day of __________, 2004 at Dumaguete City, Philippines.