Full Name of the Shareholder (required)

Shareholder’s Address: (required)

Shareholder’s NIC No./ Passport No./ Co. Reg. No. (required)

Shareholder’s Contact Number (required)

Name of the Proxy Holder

Proxy Holder’s NIC No./ Passport No./ Co. Reg. No.

Proxy Holder’s Contact Number

Shareholder’s / Proxy Holder’s Email Address: