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PROXY FORM
I, the undersigned holder (the "Shareholder") of ________ ordinary shares in the capital of ________ (the "Company") and having the following address:
________
hereby appoints ________ (the "Proxy") of the following address:
________
as my proxy to vote on my behalf at the Annual General Meeting of the Company which will hold by ________, on ________, at the following address:
________
The Proxy shall vote in the following manner:
________
SIGNED on ________.
Signature of the Shareholder
________________________
________
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