E-Dividend Mandate Activation Form.

Personal Information and Bank Detail

* Surname/Company’s Name

* Other Names

Address

Email Address

Phone Number 1

Phone Number 2

Gender:

Date of Birth

Bank Name

ONLY CLEARING BANKS ARE ACCEPTABLE

Account Number

Bank Verification Number (BVN)

Account Opening Date

Passport Photograph

Shareholder Account Information

Please list the company(ies) where you have shareholdings

Company Name

Share Holder Number

CSCS Clearing House Number (CHN)

Name of Stockbroking Firm

Declaration

I/We hereby declare that the information I have provided is true and correct and that I shall be held personally liable for any of my personal details.

I/We also agree and consent that Cordros Registrars Limited may collect, use, disclose, process and deal in any manner whatsoever with my/our personal, biometric and shareholding informations out in this form and/or otherwise provided by me/us or possessed by Cordros Registrars for administration of my/our shareholding and matters related thereto.

Signatory

Name

Name (Joint/ Company Signatories)

Date

Date (Joint/ Company Signatories)

Signature

Company Seal (if applicable)