Proximus SA — Proxy Solicitation & Information Statement 2012

Mar 16, 2012

March 2012
proxy
Extraordinary General Meeting of 18 April 2012 (11:00 a.m.)
The undersigned (name and first name/name of the company) :
Residing at/with its registered office at :
Owner of bearer shares (1) in Belgacom SA under public law registered share certificates (1) in Belgacom SA under public law quantity (1) cross out the unsuitable statement
hereby appoints the following person as a proxy: Last name and first name :
Address:
To represent him/her at the company's Extraordinary General Meeting, which will be held at 11 a.m. on Wednesday, 18 April 2012 at the Brussels 44 Center, Bd Pachéco 44, 1000 Brussels, Belgium.
Done at , 2012.
Signature(s) :
Legal persons must indicate the last name, first name and position of the persons signing this letter.