Form of Appointment of Proxy

"*" indicates required fields

I (insert full name)*

First Last

of (insert full address)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

a financial member of the ACTRVGA, appoint (insert full name of appointee)*

First Last

of (insert full address of appointee)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

a financial member of the ACTRVGA, as my proxy to vote for me on my behalf at the upcoming meeting of the association and at any adjournment of that meeting. The proxy will be voting as per my instructions.

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