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The Mica Medal

Membership Application Form

APPENDIX 1 (RULE 33.6): FORM OF APPOINTMENT OF PROXY

I, ........................................ of ................................................
(Full name) (Address)

being a member of MICA Incorporated hereby appoint

................................................ of ...............................................
(Full name) (Address)

being a member of the MICA Inc., 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

..................................... and at any adjournment of that meeting.
(Insert date)
My proxy is authorised to vote in favour of/against (delete as appropriate) the resolution (insert details if desired).

.........................................................................................................................................

............................................................
Signature of member appointing the proxy

................................
Date

NOTE: A proxy vote may not be given to a person who is not a member of the Association.