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“INTERESTED PERSONS ARE ENTITLED TO A PROSPECTUS, IF THEY SO DESIRE, AND THAT COPIES OF PROSPECTUS MAY BE OBTAINED FROM THE

ISSUER AND THE
ISSUE MANAGER”

APPLICATION FOR SHARES BY INVESTORS OTHER THAN NON-RESIDENT BANGLADESHIS
WARNING: Please read the instructions on the back of the form. Incorrectly filled applications may be rejected.

The Managing Director
Bankers Sl No.
Asia Insurance Limited.
th
T. K. Bhaban (7 floor), 13, Karwan Bazar, Dhaka-1215, Bangladesh.

Dear Sir,
I/we apply for and request you to allot me/us the ……………………. number of Shares and I/we agree to accept the same or any smaller
number that may be allotted to me/us upon terms of the Company’s approved Prospectus and subject to the Memorandum and Articles of
Association of the Company. Further, I/we authorize you to place my/our name(s) on the Register of Member(s) of the Company and deposit
the said shares to my/our Depository (BO) Account and/or a crossed (A/C Payee Only) cheque in respect of any Application money refundable
by post/courier at my/our risk to the first applicant’s address stated below:

1. No. of Ordinary Shares ........................of Tk. 100.00 each at par
2. Amount Tk. (in figure) .........................., Taka (in words) ........................................... only deposited vide Cash/
Cheque/Draft/Pay Order No...................Date..................... on..................... Bank.................…Branch
3. Depository (BO) Account Number

{If you do not mention your valid Depository (BO) Account, your application will be treated invalid.}
4. I/we agree to fully abide by the instructions given herein.
Particulars of Applicant(s) :
Sole/First Applicant : Mr./Mrs./Ms.
Father’s/Husband’s Name :
Mother’s Name:
Postal Address :
Telephone :

Occupation : Nationality :
For refund warrant (Application will not be treated as valid if anyone uses a non-scheduled bank. To avoid
this complication, investors are requested not to use the name of any non-scheduled bank) Please write the
correct and full name of bank and branch.
Applicant’s Bank A/C No. :
Name of the Bank : Branch:

Second Applicant : Mr./Mrs./Ms.
Father’s/Husband’s Name :
Mother’s Name:
Postal Address :
Occupation : Contact no. Nationality:

5. I/we hereby declare that I/we have read the Prospectus of Asia Insurance Limited, and have willingly subscribed for
………………………...... no. of Shares of Tk. 100.00 each at par.

6. Specimen Signature(s) :
Name in Block Letters Signature
(i)

(ii)

………………………………….……………..……………………………………………………………….…………………………………………………………

BANKER’S ACKNOWLEDGEMENT

Certified that this Bank has received Tk................................. (in word......................................................) only from Mr./Mrs./Ms.
............................................................................................................................... being the Application money for …....................... Nos. of
Ordinary Shares of Asia Insurance Limited.

Banker’s SL. No. Authorized Signature
Seal & Date (Name & Designation)
INSTRUCTIONS

1. As per provision of Depository Act, 1999 and regulations made there under shares will only be issued in dematerialized condition. Please mention
your BO (Beneficiary Owner) Account number in the Application form. If you do not mention your valid BO (Beneficiary Owner) Account, your
application will be treated invalid.
2. All information must be typed or written in full (in Block letters) in English or in Bengali and must NOT be abbreviated.
3. Application must be made on the Company’s printed form/photocopy or typed copy/hand written form thereof.
4. Application must not be for less than 50 Ordinary Shares and must be for a multiple of 50 Ordinary Shares. Any Application not meeting this
criterion will not be considered for allotment purpose.
5. Remittance for the full amount of the Shares must accompany each Application and must be forwarded to any of the Bankers to the Issue.
Remittance should be in the form of Cash/Cheque/Bank Draft/Pay Order payable to one of the Bankers to the Issue A/C “Asia Insurance Limited”
and crossed “A/C Payee only” and must be drawn on a Bank in the same town as the Bank to which the Application form has been sent.
6. In the case of Joint Application Form, the Allotment Letter will be dispatched to the person whose name appears first on this Application Form and
where any amount is refundable in whole or in part the same will be refunded by Account Payee Cheque by post/courier service to the person
named first on this Application Form in the manner prescribed in the Prospectus.
7. Joint Application form for more than two persons will not be accepted. In case of joint Application, each party must sign the Application Form.
8. Application must be in full name of individuals or companies or societies or trusts and not in the name of firms, minors or persons of unsound mind.
Application from financial and market intermediary companies and Private Company must be accompanied by Memorandum and Articles of
Association and Certificate of Incorporation.
9. An applicant can not submit more than two applications, one in his/her own name and another jointly with another person. In case an
applicant makes more than two applications, all applications will be treated as invalid and will not be considered for allotment purpose. In
addition, whole or part of application money may be forfeited by the commission.
10. No receipt will be issued for the payment made with Application, but the bankers will issue a provisional acknowledgment to the Issue for
Application lodged with them.
11. In the case of non-allotment of securities, if the applicants’ bank accounts as mentioned in their IPO Application Forms are maintained with the
Bankers to the Issue, refund amount of those applicants will be directly credited into the respective bank accounts as mentioned in their IPO
Application Forms. Otherwise, refund will be made only through “Account Payee” cheque(s) with bank account number and name of bank branch as
mentioned in the application payable at Dhaka or Chittagong, as the case may be.
12. Allotment shall be made solely in accordance with the instructions of the Securities and Exchange Commission (SEC).
13. Making of any false statement in the application or supplying of incorrect information therein or suppressing any relevant information shall make the
Application liable to rejection and subject to forfeiture of Application money. The said forfeited Application money will be deposited in account
specified by the Securities and Exchange Commission (SEC). This may be in addition to any other penalties as may be provided for by law.
14. Applications, which do not meet the above requirements, or Applications, which are incomplete, shall NOT be considered for allotment purpose.
15. The Banker’s to the Issue shall be obliged to receive the A/C Payee Cheque(s) on the closing day of the subscription of the IPO.
16. No sale of securities shall be made, nor shall any money be taken from any person, in connection with such sale until 25 (twenty five)
days after the prospectus has been published.
Bankers to the Issue
Southeast Bank Limited National Credit & Commerce Bank National Bank Ltd. Export Import Bank of Bangladesh
Ltd. 1. Bangshal Road Br,Dhaka
1. Principal Br, Dhaka 1. Motijheel Br., 6 Motijheel C.A. Dhaka 2.Babubazar Br, Dhaka 1. Motijheel Br. Sharif Mansion Motijheel
2. Corporate Br., Dhaka 2. Karwan Bazar Br, Dhaka 3. Dilkusha Br. , Dhaka Dhaka.
3. Imamgonj Br., Dhaka 3. Dilkusha Br. 43, Dilkusha C/A, Dhaka 4. Elephant Road Br. Dhaka 2. Panthapath Br, 19/2, West Panthapath
4. Dhanmondi Br., Dhaka 4. Mirpur Br. Road # 1, Section 10, Mirpur, 5.Foreign Exchange Br. Dhaka Dhaka
5. Uttara Br., Dhaka Dhaka 6. Gulshan Br. Dhaka 3. Gulshan Br. 75, Gulshan Avenue,
6. New Elephant Rd. Br, Dhaka 5. Dhanmondi Br., Dhanmondi R/A, Dhaka 7. Imamgonj Br, Dhaka Dhaka-1212
7. Gulshan Br., Dhaka-1212. 6. Mitford Br., Dhaka 8. Dhanmondi Br., Dhaka 4. Rajuk Avenue Br. 9, Rajuk Avenue,
8. Kakrail Br., Dhaka 7. Foreign Exchange Br., Dhaka 9. Kawran Bazar Br., Dhaka Motijheel , Dhaka.
9. Motijheel Br., Motijheel C/A, Dhaka 8. Gulshan Br. 85, Gulshan Avenue, Dhaka 10. Motijheel Br., Dhaka 5. Uttara Br. H#61/A, R#7, Sector#4,
10. Kawran Bazar Br., Dhaka 9. Banani nBr., Dhaka 11. Mohakhali Br. DHAKA Uttara Model Town, Uttara, Dhaka.
11. Banani Branch, Banani, Dhaka 10. Malibagh Br., Dhaka 12. Malibagh Br. Dhaka 6. Elephant Road Br. 218, Elephant Road,
12. Bangshal Br, North South Rd, 11. Uttara Br., Dhaka 13. Mirpur Br. Dhaka Dhaka
Dhaka 12. Moghbazar Br., Dhaka 14. Z.H .Sikder M. C. Br. Dhaka 7. Agrabad Branch, Mawla Chamber,
13. New Eskaton Br. Dhaka. 13. Babubazar Br., Dhaka 15. Islampur Br. Dhaka Chittagong.
14. Agargaon Br. PKSF Bhaban, 14. Bangshal Br, Dhaka 16. Uttara Br. Dhaka 8. Jubilee Road Br. 63-64, Jubilee Road,
Mohammadpur Dhaka. , 15. Elephant Rd. Br, Dhaka 17. North brook Hall Br. Dhaka Chittagong.
15. Aganagar Br., Dhaka 16. Jatra bari Br, Dhaka 18.Lake Circus Br. Dhaka 9. Sylhet Br. Al-Hamra Shopping City,
16. Shymoli Br., Dhaka 17. Islampur Br, Dhaka 19.Mohammadpur Br. Dhaka Zinda Bazar, Sylhet.
17. Madhabdi Br., Narshingdi 18. Comilla Br., Comilla 20. Pragati Sarani Br. Dhaka 10. Bogra Br. Sheik Mansion, Borogola,
18. Ashulia Br.( Rural), Dhaka 19. Agrabad Br., Chittagong 21. Jatrabari Br. Dhaka Bogra.
19. Joypara Br. (Rural), Dohar, Dhaka 20. Khatungonj Br., Chittagong 22.Gazipur Br. Gazipur 11. Jessore Br. 37, M.K Road, Jessore
20. Narayanganj Br., Narayanganj 21. O.R. Nizam Road Br., Chittagong 23.Savar Bazar Br. Savar 12. Malibagh Br. 484, DIT Road, Malibag,
21. Khulna Br., Khulna 22. Jubilee Road Br. 5, Jubilee Road, 24. Narayangonj Br. Narayangonj Dhaka.
22. Bandar Bazar Br. (Islami Banking), Chittagong 25. Pagla bazaar Br. Narayangong 13. Ashulia Br. Rifat Square Plaza,
Shylet 23. Cox’s Bazar Br., Cox Bazar 26, Sylhet Br. Sylhet Jamgara, Savar.
23. Moulivi Bazar Br., Moulivi Bazar 24. Laldighirpar Br., Sylhet 27. Anderkillah Br. Narayangong
24. Laldighirpar Br., New Market, Sylhet 25. Khulna Br., Khulna 28. Agrabad BR. Chittagong Trust Bank Limited
25. Hetimganj Br., Sylhet 26. Rajshahi Br., Rajshahi 29. Katunganj BR. Chittagong
26. Chouhatta br. Choutatta, Sylhet 27. Feni Branch, Feni 30. Jubilee Road BR. Chittagong
1. Principal Branch, Dhaka
27. Shahjahaj Upashahar Br. Main 31. Sheikh Muzib Road BR.
2. SKB Br., Dhaka-1000
Road Sylhet. Standard Bank Limited Chittagong
3. Agrabad Br., Chittagong
28. Kulaura Br.(Rural), Moulivi Bazar 32. Pahartoli BR. Chittagong
4. Dhanmondi Br., Dhaka
29. Pathantula Br., Sylhet 1. Principal Branch, Dhaka 33. Narsingdi Br, Narsingdi
5. Gulshan Corporate Br., Dhaka
30. Agrabad Br., Chittagong 2. Foreign Exchange Br. Dhaka 34. Tangail Br, Tangail
6. Dilkusha Corporate Br. Dhaka
31. Jubilee Road Br., Chittagong 3. Topkhana Road Dhaka 35. Khulna Br, Khulna
7. CDA Avenue Br., Chittagong
32. Khatungonj Br., Chittagong 4. Imamgong br, Dhaka 36. Rangpur Br, Rangpur
8. Sylhet corp. Br, Sylhet
33. Halishahar Br, Chittagong 5. Gulshan Br. Dhaka 37. Bogra Br, Bogra
9. Millenium Corporate Br., Dhaka
34. Pahartali Br, Chittagong 6. Dhanmondi Br, Dhaka 38. Rajshahi Br, Rajshshi
10. Uttara Corporate Br., Dhaka
35. Chowmuhuni Br.(Rural), Noakhali 7. Uttara Br. Dhaka 39. Barishal Br, Barashal
11. Mirpur Br. Dhaka
36. CDA Avenue Br., Pachlaish, 8. Gulshan -1 Br. Dhaka 40. Comilla Br. Comilla
12. Naval Base Br. Potenga, Chittagong
Chittagong 9. Panthapath Dhaka Investment Corporation Bank 13. Kawran Bazar Br. Dhaka
37. Cox’s Bazar Br., Cox Bazar. 10. Banani Branch Dhaka of Bangladesh (ICB) 14. Narayangonj Br. Narayangonj
38. Chagalnaya Br. (Islami Banking), 11. Narayangong Br, Narayangong 1. Head Office, Dhaka. 15. Radission Water Garden BR, Dhaka
Feni 12. Munshikhula Br, Dhaka 2. Local Office, Nayapaltan, VIP Road,
39. Feni Branch, Feni, 13. Jubilee Road Br. Dhaka Dhaka.
40. Bashurhat Br.(Rural), Noakhali 14. Agrabad Road . Chittagong 3. Chittagong Br. Agrabad C/A,
41. Rangpur Br., Rangpur 15. Khatungong Br, Chittagong 4. Rajshahi Br., Saheb Bazar,
16. CDA Avenue Br. Chittagong Rajshahi
17. Sylhet Br, Sylhet 5. Khulna Br., Shilpa Bank Bhaban,
18. Khulna Br, Khulna 6. Barishal Br., Hemayat Uddin Road,
19. Rajshahi BR. Rajshahi Barishal.
20. Jessore Br, Jessore, 7. Sylhet Br., Chamber Building, Jail
Road, Sylhet
8. Bogra Br., Baragola, Bogra