Form of special proxy

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..... ing of creditors [or contributories] to be held on the ................. day of ............ 19 ....., or at any adjournment thereof, to vote [Here insert the word 'for' or the word 'against', as the case may require, and specify the particular resolution] the resolution numbered ................. in the notice convening the meeting. Dated this ................. day of ................. 19 .... .....

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