Form of proxy

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..... ....... of 19 .......... ................... Applicant(s) Form of proxy I, the undersigned [an unsecured creditor], of the above company hereby appoint C.D., of etc., and failing him X.Y., of etc, .....

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..... ors] and at such meeting and any adjournment thereof, to vote for me, and in my name .................. [here, if 'for', insert 'for'; if 'against', insert 'against', and in the latter case, strike ou .....

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