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Shares under PCD / Broker Account
Stockholder's Full Name (required)
Stockholder's Contact Number (required)
Stockholder's Email Address (required)
Stockholder's Government ID (Passport, Driver's License, Unified Multipurpose ID)
Name of Broker (required)
Broker's Email Address (required)
Broker's Contact Number (required)
Broker's Certification with Number of Shares (required)
I attest to the truth and veracity of the information provided above. I hereby appoint the Chairman of the Board to act as my proxy and vote accordingly in all matters to be discussed in the Annual Stockholders’ Meeting in the event I am not able to cast my vote.
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