EXHIBIT 99.2
(FRONT)
Fidelity D & D Bancorp, Inc.
Dividend Reinvestment Plan
Authorization Form
[insert name and address]
Please sign the authorization located on the
reverse side of this form and complete the
information below only if it has changed.
Name 1: ______________________________________
Name 2: ______________________________________
Street Address: ______________________________
City/State/Zip Code: _________________________
Home Telephone Number: ______________________
Business Telephone Number: ___________________
<PAGE>
(BACK)
NOTE: This Is Not A Proxy
Completion and return of this Authorization Form authorizes your enrollment
in the Fidelity D & D Bancorp, Inc. 2000 Dividend Reinvestment Plan.
Do not return this form unless you wish to participate in the Plan.
|_| Full Common Stock Dividend Reinvestment - If you check this option, you
authorize the purchase of additional shares of common stock with the
cash dividends on all shares of common stock currently or subsequently
registered in your name, as well as on the shares of common stock
credited to your Plan Account.
|_| Partial Dividend Reinvestment - If you check this option, you authorize
the purchase of additional shares of common stock with the cash
dividends on _______ shares of Fidelity D & D Bancorp, Inc. common
stock held by you in certificate form and to apply these dividends to
the purchase of Fidelity D & D Bancorp, Inc. common stock. I understand
that I must enroll a minimum of 50 shares of Fidelity D & D Bancorp,
Inc. common stock to participate in the plan under this provision.
I understand that the purchases will be made under the terms and
conditions of the Dividend Reinvestment Plan as described in the Plan
Prospectus that accompanied this Authorization Form and that I may
revoke this authorization at any time by notifying Fidelity D & D
Bancorp, Inc., in writing, of my desire to terminate my participation.
I appoint Fidelity D & D Bancorp, Inc., or any other corporation or
bank that may succeed it under the Plan, as my agent to act in
accordance with and subject to the terms and conditions of the Plan.
Please return this Authorization Form in the envelope provided to:
FIDELITY D & D BANCORP, INC.
Attn: Dividend Reinvestment Plan
Blakely and Drinker Streets
Dunmore, Pennsylvania 18512
Sign here exactly as name(s) appear on stock certificate(s). If shares
are held jointly, all holders must sign.
Stockholder X______________________________Date___________
Stockholder X______________________________ Date___________
Social Security Number or Taxpayer Identification Number must be entered:
Name: __________________________ SSN/TIN:___________________
Name: __________________________ SSN/TIN: __________________
