FIRST  SCHEDULE

PROXY  FORM

I,                                                                                                                                                                                                                     being a practising/declared* member of (insert name of relevant society)                                                                                                     having the office at which I habitually practise at

†_____________________________________________________________________________________

†_____________________________________________________________________________________ hereby appoint

________________________________________________________________________ being a member of (insert name of relevant society),                                                                               , of ________________________________________________ or failing him/her the chairperson of the meeting as my proxy to vote for me and in my name at a meeting of members of (insert name of relevant society), to be held on the________day of____________ 20_______________ or at any adjournment thereof on the following subjects and in the following manner:

(Indicate instructions to proxy by means of a cross in relevant space.)

I further authorise my proxy to vote in such a manner as he may deem best fitted to achieve my will as above instructed on any motion of course relating to the original motion concerned.

SIGNED this _________day ___________________________________ of 20___________________

_________________________________

Signature

Proxy's endorsement in terms of rule 25.5.4 indicating his election where he is authorised to vote on a subject as he thinks fit or on a motion of course:

(Proxy to indicate election by means of a cross in relevant space.)

Proxy holder's signature: ______________________________

Notes