HSBC BANK FINANCE DEPARTMENT

15-17 Praed St, Tyburnia, London W2 1NJ

0345-740-4404 • www.hsbc.co.uk

Apostille/Certificate of Authentication Request Form

Submit this form with your documents. Please print or type.

Country documents will be used in: POLAND Number of documents to be authenticated: N56987

Requestor's Name: ALEKSANDER LUKASHENKO

Name of Firm/Organization (If applicable): BTQ INK.

Address: BELARUS, DROZDY 25

Daytime telephone number: +3753311111111 Email address: yanederzhuszakreslo@mail.ru

Fees Calculation:
Apostille: Number of documents: N56987 X $50.00 per document = Net Total: 200 USD
Certification: Number of documents: 3 X $80.00 per document = Net Total : 240 USD
Fee Amount Due : 440 USD

Form of Payment Enclosed or Authorized:

Check drawn on U.K. bank (Checks/Money Orders must be payable to HSBC Bank details.) Note: A 4% convenience fee will be
added to all credit/
Money Order from a U.K. bank debit card transactions.

Credit/Debit Card: Visa MasterCard American Express Discover

Name as it appears on Card: ALEKSANDER LUKASHENKO

BillingAddress: MY RESIDENTION City: Minsk State: Minskaya Zip Code: 220019
Card Number: 5512 3154 6485 1235 Expiration: 07/2027

Payment Authorization; I confirm that I pay for the apostille procedure, to confirm the translation of documents according to the rules of the
receiving party, to credit my funds received on the financial market..

Cardholder’s Signature:

Date: 10.08.2023

ARF-01 (Rev. 08/23)