REGISTER OF BENEFICIAL OWNERS

Company Name
Company Registration
Number

Date on
Residential Date of Nature of Date on which
which a
and service Birth of Nationality of Interest a person
Name of Beneficial If interest held by nominee person
Address of the the the Beneficial held ceased to be a
Owner became a
Beneficial Beneficial Owner Beneficial
Beneficial
Owner Owner Owner
Owner
Name and Residential
Address, service
address, date of birth
and nationality of each
nominee
Particulars and details
of the interest held by
nominee
Name and Residential
Address, service
address, date of birth
and nationality of each
nominator

Dated