‫ﺑﺴﻤﻪ ﺗﻌﺎﻟﯽ‬

‫ﺷﺮﮐﺖ ﺑﻮرس ﮐﺎﻻي اﯾﺮان )ﺳﻬﺎﻣﯽ ﻋﺎم(‬

‫ﻓﺮم درﺧﻮاﺳﺖ ﮐﺪ ﻣﺸﺘﺮﯾﺎن ﺣﻘﻮﻗﯽ‬

‫ﺷﻤﺎره ﺳﺮﯾﺎل‪:‬‬
‫…………‬ ‫ﺗﺎرﯾﺦ‪/ .…....….... /…...…… :‬‬

‫ﮐﺪ اﻗﺘﺼﺎدي‪:‬‬ ‫………‪....................…..…….….......………………….......…………………....................‬‬ ‫ﻧﺎم ﺷﺮﮐﺖ ‪:‬‬

‫…‪............................………….........................................…..……………..……...........….............‬‬ ‫زﻣﯿﻨﻪ ﻓﻌﺎﻟﯿﺖ ‪:‬‬ ‫…‪...............................…..…………………..….............….............‬‬ ‫ﻧﻮع ﺷﺨﺼﯿﺖ ﺣﻘﻮﻗﯽ ‪:‬‬
‫‪.......................…….……......‬‬ ‫ﺗﺎرﯾﺦ ﺛﺒﺖ ‪:‬‬ ‫‪.......................……………........….......‬‬ ‫ﻣﺤﻞ ﺛﺒﺖ ‪:‬‬ ‫‪............................……………………………......…… ………...…...……...........….......‬‬ ‫ﺷﻤﺎره ﺛﺒﺖ ‪:‬‬
‫………‪……………..………………....………......………..........…………................‬‬ ‫ﭘﺴﺖ اﻟﮑﺘﺮوﻧﯿﮑﯽ ‪:‬‬ ‫………‪……………………...……….....……………………................‬‬ ‫ﺳﺎﯾﺖ اﻟﮑﺘﺮوﻧﯿﮑﯽ ‪:‬‬
‫………‪……..……….……..………...………......………...........................................................................................................................................................................................................................‬‬ ‫آﺧﺮﯾﻦ آدرس دﻓﺘﺮ ﻣﺮﮐﺰي ‪:‬‬
‫………‪…………............................….………................……….…................….....……............‬‬ ‫ﮐﺪ ﭘﺴﺘﯽ ‪:‬‬
‫…………‪....………….……………….……....……...................................‬‬ ‫دورﻧﮕﺎر‪:‬‬ ‫…………‪....…………..……………….……....………….................................‬‬ ‫ﺗﻠﻔﻦ دﻓﺘﺮ ﻣﺮﮐﺰي‪:‬‬

‫ﻣﺸﺨﺼﺎت ﻋﻤﻮﻣﯽ‬
‫…………………………………‪……….………….……..………..…..………….......…..........‬‬ ‫ﻣﺪﯾﺮﻋﺎﻣﻞ‪:‬‬
‫آﺧﺮﯾﻦ ﺗﺮﮐﯿﺐ اﻋﻀﺎي ﻫﯿﺎت ﻣﺪﯾﺮه ‪:‬‬
‫‪...................................................................................................................................................................................................................................................................................................................................….........................................................................................‬‬

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

‫ﺻﺎﺣﺒﺎن اﻣﻀﺎي ﻣﺠﺎز ﺑﺮ اﺳﺎس ﺗﺼﻤﯿﻤﺎت آﺧﺮﯾﻦ ﻣﺠﻤﻊ ﺷﺮﮐﺖ ‪:‬‬

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

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

‫ﺳﻬﺎﻣﺪاران ﺑﺎﻻي ده درﺻﺪ )ﺷﺎﻣﻞ ده درﺻﺪ( ‪:‬‬

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

‫‪................................................................................................................................................................................................................................................................................................................................................................................................................................‬‬

‫‪...................................................................…………...............................................................………………………......………................………........................................................................................................................................................................................‬‬ ‫اﻃﻼﻋﺎت ﺣﺴﺎب ﻫﺎي‬

‫ﺣﺴﺎب ﺑﺎﻧﮑﯽ‬ ‫‪1‬‬

‫ﮐﺪ ﺷﻌﺒﻪ‪:‬‬ ‫ﻧﺎم ﺷﻌﺒﻪ‪:‬‬ ‫ﻧﺎم ﺑﺎﻧﮏ‪…..……………...…..………......................................................................………… :‬‬

‫ﺑﺎﻧﮑﯽ‬

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

‫…………‪............................................................…..……………...…..….........................................................‬‬ ‫ﺷﻤﺎره ﺣﺴﺎب‪:‬‬ ‫ﻧﻮع ﺣﺴﺎب‪…..……………...…..……….............................................................………… :‬‬

‫ﺿﻤﻦ ﺗﺎﯾﯿﺪ ﺻﺤﺖ ﻣﻨﺪرﺟﺎت ﻓﻮق اﻋﻼم ﻣﯽ دارم ﮐﻪ ﻫﺮﮔﻮﻧﻪ ﺗﻐﯿﯿﺮات اﺣﺘﻤﺎﻟﯽ را ﺳﺮﯾﻌﺎ ﺑﻪ آن ﺷﺮﮐﺖ ﮐﺎرﮔﺰاري اﻃﻼع دﻫﻢ‪.‬‬
‫ﺗﺎرﯾﺦ‪:‬‬ ‫ﻣﻬﺮ ﺷﺮﮐﺖ‪:‬‬ ‫اﻣﻀﺎء ﺻﺎﺣﺒﺎن ﻣﺠﺎز‪:‬‬
‫ﻣﻬﺮ ﺷﺮﮐﺖ‬ ‫ﻧﻤﻮﻧﻪ اﻣﻀﺎء ﺻﺎﺣﺒﺎن ﻣﺠﺎز‬

‫ﻣﻬﺮ و اﻣﻀﺎي واﺣﺪ ﺻﺪور ﮐﺪ‬ ‫ﮐﺪ ﺻﺎدره ﺗﻮﺳﻂ ﺑﻮرس‬

‫ﻧﺴﺨﻪ دوم‪ :‬ﺑﻮرس‬ ‫ﻧﺴﺨﻪ اول‪ :‬ﮐﺎرﮔﺰار‬

‫ﺑﺎﻧﮏ و ﻧﻮع ﺣﺴﺎب ﺗﻮﺳﻂ ﺑﻮرس ﺗﻌﯿﯿﻦ ﻣﯽ ﮔﺮدد‪.‬‬ ‫‪-1‬‬