| Name of nominee shareholder: ..………. |
| 1. | Full name of the person for whom the shareholder is a nominee: …………………………………………………… |
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2. | Aliases, if any of the person for whom the shareholder is a nominee: …………………………………………………… |
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| | 3. | Residential address of the person for whom the shareholder is a nominee: …………………………………………………… |
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| | 4. | Nationality of the person for whom the shareholder is a nominee: …………………………………………………… |
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| | 5. | Identity card number or passport number of the person for whom the shareholder is a nominee: …………………………………………………… |
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| | 6. | Date of birth of the person for whom the shareholder is a nominee: …………………………………………………… |
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| | 7. | Date on which the shareholder became the nominee of the person for whom the shareholder is a nominee: …………………………………………………… |
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| | 8. | Date on which the shareholder ceased to be a nominee of the person for whom the shareholder is a nominee: …………………………………………………… |
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| | 9. | Where there is any change to the particulars of the person for whom the shareholder is a nominee — |
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| | (a) | the new particulars: ………………………………………… |
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| | (b) | the date on which the particulars changed: ………………………………………… |
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| | 1. | Name of the person for whom the shareholder is a nominee: …………………………………………………… |
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| | 2. | Unique entity number of the person for whom the shareholder is a nominee issued by the Registrar, if any: …………………………………………………… |
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| | 3. | Address of registered office of the person for whom the shareholder is a nominee: …………………………………………………… |
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| | 4. | Legal form of the person for whom the shareholder is a nominee: …………………………………………………… |
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| | 5. | Jurisdiction where, and statute under which, the person for whom the shareholder is a nominee is formed or incorporated: …………………………………………………… |
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| | 6. | Name of the corporate entity register of the jurisdiction where the person for whom the shareholder is a nominee is formed or incorporated, if applicable: …………………………………………………… |
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| | 7. | Identification number or registration number on the corporate entity register of the jurisdiction where the person for whom the shareholder is a nominee is formed or incorporated, if applicable: …………………………………………………… |
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| | 8. | Date on which the shareholder became the nominee of the person for whom the shareholder is a nominee: …………………………………………………… |
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| | 9. | Date on which the shareholder ceased to be a nominee of the person for whom the shareholder is a nominee: …………………………………………………… |
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| | 10. | Where there is any change to the particulars of the person for whom the shareholder is a nominee — |
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| | (a) | the new particulars: ………………………………………… |
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| | (b) | the date on which the particulars changed: ………………………………………… |
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