FORM G LEGAL PROFESSION ACT (CHAPTER 161) LEGAL PROFESSION (INTERNATIONAL SERVICES) RULES RULES 22 AND 3708) "APPLICATION FOR RELEASE / ‘AUTHORIZATION AND REGISTRATION TO PROCESS DONATIONS FOR INTERNATIONAL BENEFICIARIES. (SECTION 150). Section A - Particulars of Applicant (a) Particulars Title (tick as applicable) Mrs [[] Miss[_] Ms [[] Other (please state) (an a) Name in full: v Dodecs Jaren 8e Rivrss TAs in passpor or ather identification Geoument, Please underiine surname.) NRIC. eye Passport No. safes) Present ere Date of birth: Febru: ge at dag of application: ‘OA ueas_old Correspondence address wetnig to _sycaut_ “i, ha eelen Mortal status. Single Next of Kin. Beat i Qi ie ye, Jarsmillo Postal code: eT Telephone No ‘34 6166 gyi Fax No. Email Address 4 258 @ 40% “\con | S2qfiis.den. here by decare tha the informations provided in this form are confirm informations of mine and i will be held responsible if otherwise. Gos feo Cereal // Beneficiary Signature