Admission and Access Procedure
Annex 3 to the Admission and Access Procedure
Authorized Representatives Form
Capitalized terms and expressions used in this Authorized Representatives Form shall have the respective meanings given to them in the Market Rules, as amended from time to time and published in the Belgian Official Gazette and in the Market Procedures as amended from time to time and published on the Belpex website
Applicable situation (circle the right number)
- Initial designation of the authorized representatives by
a.Applicant
b.Person applying as Indirect Participant
- Modification of the designation of authorized representatives by
a.Participant
b.Indirect Participant
In this case, provide the date on which these modifications shall enter into force:
(the provided date must be at least five (5) Days later than the submission date of the Authorized Representatives Form)
The Applicant/Participant/Person applying as Indirect Participant/Indirect Participant
Name:
Legal form of company:
Jurisdiction of incorporation:
Address (registered office/domicile):
City:
Country:
Company number/commercial register number:
Other relevant identification number (with indication of nature of such identification number):
validly represented by and ,
I) declares that it may validly be represented by the following directors or managers
- Directors
Name:
Function:
Name:
Function:
Name:
Function:
Name:
Function:
Each acting alone or ______
- Managers
Name:
Function:
Name:
Function:
Name:
Function:
Name:
Function:
Each acting alone or ______
and due evidence of such authority and of identity is attached hereto.
II) hereby appoints the following Persons:
A)
1.
Name:
Function:
Address:
City:
Country:
Telephone:
Fax:
E-mail:
Signature (specimen):
2. [If applicable]
Name:
Function:
Address:
City:
Country:
Telephone:
Fax:
E-mail:
Signature (specimen):
3. [If applicable]
Name:
Function:
Address:
City:
Country:
Telephone:
Fax:
E-mail:
Signature (specimen):
to do any of the following in relation to the participation to and the trading on the Belpex Spot Market, in the name and on behalf of the Applicant/Participant/Person applying as Indirect Participant/Indirect Participant, each of the aforesaid Persons having the power to act alone:
a) Sign any agreement or modification thereof and make all necessary declarations or acts relating to Applicant's/Participant's/Person applying as Indirect Participant's/Indirect Participant'sAdmission and Access to the Belpex Spot Market, in particular sign the Application Form Admission and Access Belpex Spot Market, the Participation Agreement
or the Indirect Participation Agreement (where applicable) and any modification thereto, or designate an ARP;
b) Take any actions and do all things that are necessary or useful to fulfill the obligations of the Applicant/Participant/Person applying as Indirect Participant/Indirect Participant or are otherwise required or appropriate in respect of the due fulfillment by the Applicant/Participant of the Participation Agreement, or by the Person applying as Indirect Participant/Indirect Participant/Participant of the Indirect Participation Agreement as the case may be.
B)
1.
Name:
Function:
Address:
City:
Country:
Telephone:
Fax:
E-mail:
Signature (specimen):
2. [If applicable]
Name:
Function:
Address:
City:
Country:
Telephone:
Fax:
E-mail:
Signature (specimen):
3. [If applicable]
Name:
Function:
Address:
City:
Country:
Telephone:
Fax:
E-mail:
Signature (specimen):
to do any of the following in relation to the participation to and the trading on the Belpex Spot Market, in the name and on behalf of the Applicant,Person applying as an Indirect Participant, Participant or Indirect Participant, each of the aforesaid Persons having the power to act alone:
- Communicate any modification to the contact information of the Applicant/Participant provided in the Participant Contact Information Form;
- In case of an Applicant or Participant: take any actions regarding the Position Account(s) of the Applicant/Participant provided in the Position Account Form, in accordance with the Market Rules;
- In case of an Applicant or Participant: take any actions and do all things that are necessary or useful regarding the appointment of the Authorized User(s) of the Applicant/Participant provided in the Authorized User Form, in accordance with the Market Rules.
The Applicant/Participant/Person applying as Indirect Participant/Indirect Participantrepresents that the authorized representative(s) designated in this Authorized Representatives Form is/are designated in accordance with the articles of association of the Applicant/Participant/Person applying as Indirect Participant/Indirect Participant and/or any applicable law and regulation and that they are validly empowered.
The Applicant/Participant/Person applying as Indirect Participant/Indirect Participant irrevocably and unconditionally undertakes to notify Belpex in writing of any revocation, termination event or other changes affecting this Authorized Representatives Form (it being understood that such revocation, termination or other change shall take effect on the fifth Day following Belpex' receipt of such written notice) and it shall substantially contemporaneously provide Belpex with a new Authorized Representatives Form.
The undersigned represent(s) that he/they is/are duly authorized as director/[other title] of the Applicant/Participant/Person applying as Indirect Participant/Indirect Participantto execute in its name and on its behalf this Authorized Representatives Form, and due evidence of such authority is attached hereto. The undersigned represents/represent that this Authorized Representatives Form complies with all formal and substantive requirements applicable under the law of the jurisdiction of incorporation of the Applicant/Participant/Person applying as Indirect Participant/Indirect Participant, including without limitation witnessing, legalization and authentication requirements.
Place, date:
Name:
Signature:
In the presence of:
Signature:
Place, date:
Name:
Signature:
In the presence of:
Signature:
Authorized Representatives Form 1/6September 14th, 2012
Strike out what is not applicable.
In some jurisdictions, signature of a notary or witness may be required.