Use this template to prepare a Proxy Ballot on resolution upon a call for a poll. This form of ballot would be used at shareholder meetings if a poll is called for with respect to a resolution put before the meeting.

The form can be used by a shareholder who is voting both his / her own shares and shares he / she is voting as a proxy. The votes can be distributed between "For" and "Against".

This is a generic corporate form in MS Word format, and is not specific to any country or region.