Use this template to prepare a Shareholder 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 only by a shareholder who is voting his / her own shares, and NOT for shares he / she is voting as a proxy.

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