Directors & Officers

Directors & Officers

Proposal form
Please provide with this proposal form the most recent copies of the following documents:
• Proposer’s audited annual report and accounts
• Organisation structure chart
• Any financials filed with the US Securities and Exchange Commission
• Any offering document/listing particulars published in the last three years
• Any supplementary information which is material to the response of the questions
Name of the Proposer
Name of the Parent Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Please state the total assets from the latest audited financial report:
Date of establishment:

MonthDayYear
Date

Please provide the approximate geographical split of total assets:

	Percentage Split
Africa %
Arab States %
Asia %
Canada %
Caribbean %
Central and Eastern Europe %
South America %
Rest of World %
Western Europe %
UK %
USA %

Please state:


total number of shareholders:
b. total number of shares issued:
c. total number of shares held by directors (both direct and beneficial):

Are equity securities of the Proposer traded on a stock exchange?
If ‘Yes’, please provide details of the stock exchange(s) and ticker symbol(s):
How much of issued share capital forms part of the free float?
Are there any shareholders who own 10% or more of the issued shares:
If ‘Yes’, please provide details:
Are any equity securities traded in the USA?
If ‘Yes’, please state the type of listing:

Level 1 sponsoredLevel 1 unsponsoredLevel 2Level 3Full listing
Please state the percentage of market capitalisation that is traded in the USA?
%
Does the Proposer have any acquisition or merger pending or intend a new public offering of equity securities within the next 12 months?
If ‘Yes’, please provide details:
Please read the following statements and confirm as indicated below:
a. No claim, proceeding or demand has been made or brought against the Proposer or any of its directors,
officers or employees in the last five years (whether insured or not);
b. The Proposer or any of its directors, officers or employees have not been the subject of any regulatory,
administrative or governmental investigation in the last five years (whether insured or not);
c. The Proposer, after enquiry, is not aware of any act, error, omission, event, circumstance or incident which may
give rise to a claim, proceeding or demand or any regulatory, administrative or governmental investigation.
All the statements above are true and accurate:
If ‘No’, please provide details below or on a separate sheet
Should be Empty: