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WE, the , being a body corporate, and one of the proprietors of the company, do hereby appoint A.B., of , who is hereby certified to be a member of this corporation, to vote in our name as he shall think proper upon any matter relating to the said undertaking proposed at the meeting of the proprietors of the said company to be held on the day of next, or at any adjournment thereof.
In witness whereof the common seal of the said corporation, attested as is required by its regulations, is set hereto this day of
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