Selvita S.A. — Proxy Solicitation & Information Statement 2024

May 24, 2024

POWER OF ATTORNEY

for representation at the General Meeting

I. SHAREHOLDER DATA

Name:
Address:
Court of Registration and Division:
KRS no:
Capital:
Foreign Entity Registration Data:
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 20 th, 2024. 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:

_________________________________________________________________________________

__________ no. __________________________. 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.