Dematerialization Form.

Personal Information and Bank Detail

Passport Photo

Name of Register:

Shareholder’s full names:

Address:

GSM No:

CSCS Investor’s Acct. No:

Bank Name:

BVN:

Registrars ID No. (RIN):

Clearing House Number (CHN):

Bank Account Name:

Bank Account No (NUBAN):

E-mail Address:

Stockbroker Information

Name of Stockbroker:

Member Code:

Certificate Details

S/No. CERTIFICATE No. UNITS

TOTAL

Indemnity for lost, misplaced or destroyed certificate(s)

This is to be executed by the shareholder’s stockbroker, banker or insurance company

Indemnity Statement

Requirements

1. Copy of Current CSCS Statement; 2. CSCS Transaction History; 3. CSCS Certificate Deposit Listing; 4. Board Resolution with Seal (for corporate shareholders); 5. Copy of VALID Means of Identification with Original for sighting; 6. Completed Share Transfer Form.