I, Franchisee Name, hereby name and appoint

NAME OF PROXY

as the PROXY of the undersigned at the Regular Meeting of the GENERIKA FRANCHISE ADVISORY
BOARD to be held on 16/17 February 2018, at XX:00 X.M. at
_____________________________________________, and at any postponement or adjournment
thereof.

Date of Giving of Proxy

Franchise Name
Franchisee

By:

__________________________________
NAME OF PROXY
Attorney-in-Fact