COMPANIES ACT, 10929

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List of Persons holding Shares in the
Company, Limited, on the day of 19 ,
and of Persons who have held Shares therein at any time since the
date of the last Return, or (in the case of the first Return) of the
incorporation of the Company, showing their Names and Addresses,
and an Account of the Shares so held.
N.B.—If the names in this list are not arranged in alphabetical
order, an index sufficient to enable the name of any person in the
list to be readilv found must be annexed to this list.

Folio in
Register
Ledger
containing
Particulars

NAMES, ADDRESSES
AND OCCUPATIONS

“Number
f Shares
neld by
existing
embers
i Date of
Return

ACCOUNT OF SHARE:

+ Particulars of
Shares transferred
since the date of
he last Return, or
in the case of the

first Return) of
the incorporation
of the Company,
by Persons who
are still Members

1 Particulars of
Shares transferrec
since the date of
‘he last Return, or
‘in the case of the

first Return) of

the incorporatior
of the Company,
by Persons who
have ceased to be

Members

Num
ber -

Date of
Registra-
tion of
Trancfar

Nurr
be

ate of
Registra
tion of

Nranc<fer

(Signature)
‘State whether Director or Manager or Secretar

* The aggregate Number of Shares held, and not the Distinctive Numbers, must be stated,
and the column must be added up throughout so as to make one total to agree with that stated
in the Summary to have been taken up.

t+ When the Shares are of different classes these columns may be subdivided so that the number
of each class held, or transferred, may be shown separately. “Where any Shares have been con-
verted into Stock the amount of Stock held by each member must be shown.

1 The date of Registration of each Transfer should be given as well as the Number of Shares
transferred on each date. The Particulars should be placed opposite the name of the Transferor,
and not opposite that of the Transferee, but the name of the Transferee mav be inserted in the
* Remarks” column immediately opposite the particulars of each Transfer