I __________________________________________________________,

of _________________________________________________________

being a member of ___________________________________________

(Name of Incorporated Association)

hereby appoint______________________________________________

of_________________________________________________________

being a member of that incorporated Association, as my proxy to vote for me on my behalf at the general meeting of the Association (annual general meeting or special general meeting, as the case may be) to be held on the

_________ day of __________________ 20____

and at any adjournment of that meeting.

My proxy is authorised to vote in favour or against (delete as appropriate) the resolution (insert details):

___________________________________________________________

___________________________________________________________

___________________________________________________________

Signed____________________________

The_______day of____________20____