Proxy Form

Appendix 2 - Form of appointment of proxy

I,

First Name

Last Name

of

Address

Street Address

Suburb

State

Postcode

a member of the Belnorth Football Club Incorporated

appoint

First Name

Last Name

of

Address

Street Address

Suburb

State

Postcode

a member of the Belnorth Football Club Incorporated, as my proxy to vote for me on my behalf at the general meeting of the Belnorth Football Club Incorporated (annual general meeting or other general meeting, as the case may be) to be held on

Date / Time of meeting

and at any adjournment of that meeting.

*My proxy is authorised to vote in favour of/against the resolution (insert details below)

Resolution

Signature of member

Sign Here

Note: A proxy vote may not be given to a person who is not a member of the association

Contact details of Member appointing the proxy

Phone

Email