Appointment of Proxy Form

Please fill out the form below to appoint a proxy to vote for you on your behalf in all matters arising at specific events.

    Event Name (required)
    Event Date (mm/dd/yyyy - required)

    I, (name in full, required)
    of address (required)

    being a life member of the Peradeniya Medical School Alumni Association- Australasia hereby appoint;

    Full name of proxy (required)
    of address (required)

    being a life member of that Peradeniya Medical School Alumni Association- Australasia, as my proxy to vote for me on my behalf in all matters arising at the event outlined above.

    Date (mm/dd/yyyy - required)