TICK ACCOUNT NO.

Bank Verification Number

Bank Name

Bank Account Number

Shareholder Account Information

Surname / Company’s Name

First Name Other Names

Address :

City State Country

Previous Address (If Any)

StockBroker’s Name

Clearing House Number CHN (If any)

Mobile Telephone 1 Mobile Telephone 2

Email Address

Signature(s) Company Seal (If applicable)

Joint\Company’s Signatories

NAME OF COMPANY

AC0RN PET. PLC

AFRIK PPHARMACEUTICALS PLC

AG HOMES SAVINGS & LOANS

AG LEVENTIS

ARBICO PLC

ASHAKACEM PLC

BANKERS WAREHOUSE

BETA GLASS

CAPITAL HOTEL PLC

ELLAH LAKES

EVANS MED PLC

FCMB BOND

FCMB GROUP PLC

FIDSON BOND

G. CAPPA PLC

GUINEA PLC

IMB ENERGY MASTER FUND

JOS INT. BREWERIES PLC

KOGI SAVINGS & LOAN LTD

LAFARGE AFRICA PLC

LAFARGE BOND

LAW UNION & ROCK PLC

LEGACY FUND

LIVESTOCK FEEDS PLC

MORISON PLC

MRS OIL PLC

NAHCO BOND

NAHCO PLC

NEWPAK PLC

N.G.C PLC

NGC STERILE

NPF MICROFINANCE BANK

NULEC INDUSTRIES PLC

OKOMU OIL PALM PLC

PREMIER PAINT PLC

REAN PLC

SKYE BANK PLC

TOTAL NIG. PLC

TRANEX PLC

WOMEN INVESTMENT FUND

The Registrar,CardinalStone Registrars, Limited358, Herbert Macaulay Way, Yaba,P.M.B 1007, Sabo Yaba, LagosNigeria.

I\We hereby request that henceforth, all my\our Dividend Payment(s) due to me\us from my\our holdings in all the companies ticked at te right hand column be credit directly to my\our bank detailed below

Date of Birth:

Next of Kin Name

Next of Kin Mobile Number

Next of Kin Address (If different from the above address)