Fillable Form of Proxy - Mosquito Consolidated Gold Mines Limited
MOSQUITO CONSOLIDATED GOLD MINES LTD.
9th Floor, 100 University Avenue Toronto, Ontario M5J 2Y1 www.computershare.com
MR SAM SAMPLE 123 SAMPLES STREET SAMPLETOWN SS X9X 9X9
Security Class Holder Account Number
Form of Proxy - Annual and Special General Meeting to be held on December 16, 2011 This Form of Proxy is solicited by and on behalf of Management.
Notes to proxy
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