Proxy for the
Representation of a HIC Member at the General Assembly
Cairo, 6 September 2005
I, (full name of donor):_____________________________________________
In representation of :(Organization)___________________________________
Address: (of Organization):__________________________________________
HIC Membership Code:____________________________________________
by this statement, give a proxy to:
Proxy’s full name :_________________________________________________
Proxy’s address : _________________________________________________
Organization:_____________________________________________________
to represent the Organization in the HIC General Assembly to be held in Cairo, Egypt, on September 6th of 2005 and to vote in my place.
________________ _________
Signature of Donor Date
