Email:

{Email:13}

Banks Legal Staff:

{Banks Legal Staff:19}

Full Name of Grantor

{FULL NAME OF GRANTOR:1}

Nationality of Grantor

{NATIONALITY OF GRANTOR:2}

Passport Number of Grantor

{PASSPORT NUMBER OF GRANTOR:3}

Position/Capacity of Grantor

{POSITION/CAPACITY OF GRANTOR:15}

Full Legal Name of The Company

{FULL LEGAL NAME OF THE COMPANY:4}

State in which the Company is Incorporated

{STATE IN WHICH THE COMPANY IS INCORPORATED:5}

Office Address

{STATE IN WHICH THE COMPANY IS INCORPORATED:5}

Country in which the Company is Incorporated

{COUNTRY IN WHICH THE COMPANY IS INCORPORATED:6}

Company Registration Number

{COMPANY REGISTRATION NUMBER AS PER COMMERCIAL REGISTRATION OF THE COMPANY:11}

Name of Pursuant to which the Company is Authorized

{NAME OF DOCUMENT PURSUANT TO WHICH THE GRANTOR IS AUTHORIZED:7}

Date of Document Pursuant to which the Company is Authorized

{DATE OF DOCUMENT PURSUANT TO WHICH THE GRANTOR IS AUTHORIZED:8}

Include Power to Sub-deligate

{Date:21}

Banks Legal Staff to be Appointed as your Attorneys

{WHICH BANKS LEGAL STAFF MEMBERS DO YOU WISH TO APPOINT AS YOUR ATTORNEYS?:9}