[Complete one entry in the register for each nominee shareholder]
Date of entry: ……
Name of nominee shareholder: ..……….
Part 1*
1.
Full name of the person for whom the shareholder is a nominee: ……………………………………………………
2.
Aliases, if any of the person for whom the shareholder is a nominee: ……………………………………………………
3.
Residential address of the person for whom the shareholder is a nominee: ……………………………………………………
4.
Nationality of the person for whom the shareholder is a nominee: ……………………………………………………
5.
Identity card number or passport number of the person for whom the shareholder is a nominee: ……………………………………………………
6.
Date of birth of the person for whom the shareholder is a nominee: ……………………………………………………
7.
Date on which the shareholder became the nominee of the person for whom the shareholder is a nominee: ……………………………………………………
8.
Date on which the shareholder ceased to be a nominee of the person for whom the shareholder is a nominee: ……………………………………………………
9.
Where there is any change to the particulars of the person for whom the shareholder is a nominee —
(a)
the new particulars: …………………………………………
(b)
the date on which the particulars changed: …………………………………………
Part 2**
1.
Name of the person for whom the shareholder is a nominee: ……………………………………………………
2.
Unique entity number of the person for whom the shareholder is a nominee issued by the Registrar, if any: ……………………………………………………
3.
Address of registered office of the person for whom the shareholder is a nominee: ……………………………………………………
4.
Legal form of the person for whom the shareholder is a nominee: ……………………………………………………
5.
Jurisdiction where, and statute under which, the person for whom the shareholder is a nominee is formed or incorporated: ……………………………………………………
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: ……………………………………………………
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: ……………………………………………………
8.
Date on which the shareholder became the nominee of the person for whom the shareholder is a nominee: ……………………………………………………
9.
Date on which the shareholder ceased to be a nominee of the person for whom the shareholder is a nominee: ……………………………………………………
10.
Where there is any change to the particulars of the person for whom the shareholder is a nominee —
(a)
the new particulars: …………………………………………
(b)
the date on which the particulars changed: …………………………………………
*Where the person for whom the shareholder is a nominee is an individual, complete Part 1.
**Where the person for whom the shareholder is a nominee is a legal entity, complete Part 2.
