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I am the undersigned:

Contact Address:

Telephone Number:

Fax Number:

Mobile Number:

Email Address:

Nationality:

Holder of Passport No.:

Issue Date:

Appointed as: (Manager / Director /


Secretary / Representative)

For: (Name of Company)

Kindly attest my signature appears below


Specimen Signature:

/var/www/apps/conversion/tmp/scratch_4/173966815.doc

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