Form of proxy

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..... failing him X.Y., of etc, as my proxy, to act for me at the meeting of [unsecured creditors] to be held at ........... on the ............ day of .............. 19 ........, at .................. o'clock in the .................. noon, for the purpose of considering and, if thought fit, approving, with or without modification, a compromise or arrangement proposed to be made between the said compan .....

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