Exhibit 99.3
NXT ENERGY SOLUTIONS INC |
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Security Class | |
Holder Account Number | |
Form of Proxy - Annual and Special Meeting to be held on Wednesday, June 21, 2017 This Form of Proxy is solicited by and on behalf of Management. |
Notes to proxy | |
1. | Every holder has the right to appoint some other person or company of their choice, who need not be a holder, to attend and act on their behalf at the meeting or any adjournment or postponement thereof. If you wish to appoint a person or company other than the persons whose names are printed herein, please insert the name of your chosen proxyholder in the space provided (see reverse). |
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2. | If the securities are registered in the name of more than one owner (for example, joint ownership, trustees, executors, etc.), then all those registered should sign this proxy. If you are voting on behalf of a corporation or another individual you must sign this proxy with signing capacity stated, and you may be required to provide documentation evidencing your power to sign this proxy. |
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3. | This proxy should be signed in the exact manner as the name(s) appear(s) on the proxy. |
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4. | If this proxy is not dated, it will be deemed to bear the date on which it is mailed by Management to the holder. |
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5. | The securities represented by this proxy will be voted as directed by the holder, however, if such a direction is not made in respect of any matter, this proxy will be voted as recommended by Management. |
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6. | The securities represented by this proxy will be voted in favour or withheld from voting or voted against each of the matters described herein, as applicable, in accordance with the instructions of the holder, on any ballot that may be called for and, if the holder has specified a choice with respect to any matter to be acted on, the securities will be voted accordingly. |
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7. | This proxy confers discretionary authority in respect of amendments or variations to matters identified in the Notice of Meeting or other matters that may properly come before the meeting or any adjournment or postponement thereof. |
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8. | This proxy should be read in conjunction with the accompanying documentation provided by Management. |
Proxies submitted must be received by 2:00 pm, Local Time, on Monday, June 19, 2017.
VOTE USING THE TELEPHONE OR INTERNET 24 HOURS A DAY 7 DAYS A WEEK!
• | Call the number listed BELOW from a touch tone telephone. | • | Go to the following web site: www.investorvote.com | |||||
1-866-732-VOTE (8683) Toll Free | • | Smartphone? |
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Voting by mailmay be the only method for securities held in the name of a corporation or securities being voted on behalf of another individual.
Voting by mail or by Internetare the only methods by which a holder may appoint a person as proxyholder other than the Management nominees named on the reverse of this proxy. Instead of mailing this proxy, you may choose one of the two voting methods outlined above to vote this proxy.
To vote by telephone or the Internet, you will need to provide your CONTROL NUMBER listed below.
CONTROL NUMBER
Appointment of Proxyholder | ||||
I/We being holder(s) of NXT Energy Solutions Inc. hereby appoint(s):George Liszicasz, the Chairman and Chief Executive Officer of the Corporation, or failing him,Beverly Stewart, Vice President Finance and Chief Financial Officer of the Corporation. | OR | Print the name of the person you are appointing if this person is someone other than the Management Nominees listed herein. |
as my/our proxyholder with full power of substitution and to attend, act and to vote for and on behalf of the shareholder in accordance with the following direction (or if no directions have been given, as the proxyholder sees fit) and all other matters that may properly come before the Annual and Special Meeting of shareholders of NXT Energy Solutions Inc. to be held at Norton Rose Fulbright Canada LLP, Suite 3700, 400 3rd Avenue SW,Calgary, Alberta T2P 4H2 on Wednesday, June 21, 2017 at 2:00 pm (local time) and at any adjournment or postponement thereof.
VOTING RECOMMENDATIONS ARE INDICATED BYHIGHLIGHTED TEXT OVER THE BOXES.
For | Against | |||||||
1. Number of Directors | ¨ | ¨ | ||||||
To set the number of directors atfive (5). | ||||||||
2.Election of Directors | ||||||||
For | Withhold | For | Withhold | For | Withhold | |||
01. George Liszicasz | ¨ | ¨ | 02. Charles Selby | ¨ | ¨ | 03. John Tilson | ¨ | ¨ |
04. Bruce G. Wilcox | ¨ | ¨ | 05. Thomas E. Valentine | ¨ | ¨ | |||
For | Withhold | |||||||
3.Appointment of Auditors | ¨ | ¨ | ||||||
Appointment of KPMG LLP as Auditors of the Corporation for the ensuing year and authorizing the Directors to fix their remuneration. | ||||||||
For | Against | |||||||
4.Approval of Majority Voting Policy | ¨ | ¨ | ||||||
To consider and if thought appropriate, to pass an ordinary resolution approving the adoption of a Majority Voting Policy in respect of the election of new Directors | ||||||||
For | Against | |||||||
5.Approval of Restricted Share Unit Plan | ¨ | ¨ | ||||||
To consider and, if thought appropriate, to pass an ordinary resolution approving the adoption of a Restricted Share Unit plan (“the RSU Plan”) | ||||||||
Authorized Signature(s) - This section must be completed for your instructions to be executed. | Signature(s) | Date | |||
I/We authorize you to act in accordance with my/our instructions set out above. I/We hereby revoke any proxy previously given with respect to the Meeting. If no voting instructions are indicated above, this Proxy will be voted as recommended by Management. | DD /MM /YY | ||||
Interim Financial Statements - Mark this box if you would like to receive Interim Financial Statements and accompanying Management’s Discussion and Analysis by mail. | ¨ | Annual Financial Statements - Mark this box if you would NOT like to receive the Annual Financial Statements and accompanying Management’s Discussion and Analysis by mail. | ¨ |
If you are not mailing back your proxy, you may register online to receive the above financial report(s) by mail at www.computershare.com/mailinglist.
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