I, , of , , being a member of the above-named Board, hereby appoint , of , , as my proxy to vote for me on my behalf at the Meeting of the Board, to be held o the day of 19, and at any adjournment thereof. *in favour of This form is to be used* against the following resolution/s: Signed this of 19. NOTE—Unless otherwise instructed, the proxy will vote as he thinks fit. *Strike out whichever is not desired