Nomination Form

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....a nomination and do hereby nominate the following person(s) in whom all rights of transfer and/or amount payable in respect of shares or debentures or deposits shall vest in the event of my or our death. Name(s) and Address(es) of Nominee(s) Name: ...................................................................................... Address: .................................................................................... ................................................................................................ Date of Birth* ............................................................................ *(to be furnished in case the nominee is a minor) **The Nominee is a minor whose guardian is ......................

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............................................................................ Date: ............................................. Address, Name and Signature of witnesses: ---------------                                        --------------- Name and Address                                                &....