[See Rule 73]

[Heading as in Form No. 1.]

Company Application No. ______ of 20__ _______ Application(s)

Form of Proxy

I, the undersigned [as unsecured creditor], of the above company hereby appoint Mr. ____ and Mr. ______ of etc., and failing him Mr. _____ and Mr. ____ of etc., as my proxy, to act for me at the meeting or [unsecured creditors] to be held at ______, on the ______ day of ______ 20_ at ________ o'clock in the ____ noon, for the purpose of considering and, if thought fit, approving, with or without modification, a compromise or arrangement proposed to be made between the said company and its [unsecured creditors] and at such meeting and any adjournment thereof, to vote, for me and in my name _____ [here, `if the', insert `for'; `if against', insert `against', and in the letter case, strike out the words below after `compromise or arrangement'] the said compromise or arrangement either with or without modification as my proxy may approve.

[Strike out what is not necessary]

Dated this _________ day of _______ 20__

Signature :

Address :