Representation of a HIC Member at the General Assembly

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