Selvita S.A. — Proxy Solicitation & Information Statement 2023

May 31, 2023

POWER OF ATTORNEY

for representation at the General Meeting

I. SHAREHOLDER DATA

Name:
Address:
Series and number of identity card/passport:
PESEL:
Phone:
Email:

II. PROXY DATA

Name:
Name:
Series and number of identity card/passport:
PESEL:
Phone:
Email:

I hereby grant to the Proxy indicated above, i.e. _______, the power of attorney
to represent me, a Shareholder, at the Annual General Meeting of Selvita S.A. with its registered office
in Krakow, Poland, convened for June 27th, 2023. This power of attorney authorizes the Proxy
					to exercise on my behalf all the rights to which I am entitled from ___ shares of
					Selvita S.A. in accordance with the registered certificate of the right to participate in the Annual
General	Meeting	of	Selvita	S.A.	issued	by:
					_______________

__________ nr __________________________. The proxy is authorized/not authorized¹ to appoint further proxies.

Knowing the criminal consequences of making false statements, I/we confirm that the above information is true and correct.

_________________________________________________________________________________ _________________________________________________________________________________

Additional Notes:

Place and date of issue ____________________

Signature of Shareholder ____________________

1 Delete as necessary.