NOMINATION FORM (Pursuant to Section 109A of Companies Act,1956) TO Dear Sirs, I/We___________________________ and_____________________ the holder(s) of Share Certificates bearing Nos.____________________ under Regis- tered Folio No.________________of M/s. , wish to make a nomination and do hereby nominate the following person in whom all rights of transfer and/or amount payable in respect of Shares shall vest in the event of my/our death. Name and Address of Nominee: Name:_________________________________________________________________ Address:_______________________________________________________________ Date of Birth:________________________________________________________ (To be furnished in case the Nominee is a minor) The Nominee is a minor whose guardian is (Name & Address)_____________ ______________________________________________________________________ Dated this__________________day of ____________________________20 WITNESS: REGISTERED MEMBERS: 1.Name : 1st Holders Name: Signature : Signature : Address : Address : 2.Name : 2nd Holders Name: Signature : Signature : Address : Address :