SCRIPLESS ONLY

Application Form for Payment of Substituted Payment for Dividend in Foreign Currency

To Thai NVDR Company Limited

We, ………………………………………………, the TSD participant #…………………, acting on behalf of our clients, would like to request the substituted payment for dividend paid according to the Non Voting Depository Receipts (NVDR) of a underlying security ..…………………………………… (full name) in foreign currencies as specified in the table below. The book closing date of such security is .…/.…/…. (date/month/year). Herewith are the name list of our clients who hold the NVDR of such a security and the details of the payment.

Name of the NVDR Holder / Type of Payment / Currency
(please specify only one currency per holder) / Bank Account Details
(by Telex)
First Name ……………………………...
Middle Name (if available) ……………..
Last Name ……………………………… /  Bank Draft
 Telex / Name of Bank ……………………………………
Branch ……………………………………
Bank Account # …………………………………
First Name ……………………………...
Middle Name (if available) ……………..
Last Name ……………………………… /  Bank Draft
 Telex / Name of Bank …………………………………
Branch …………………………………
Bank Account # …………………………………
First Name ……………………………...
Middle Name (if available) ……………..
Last Name ……………………………… /  Bank Draft
 Telex / Name of Bank …………………………………
Branch …………………………………
Bank Account # …………………………………
First Name ……………………………...
Middle Name (if available) ……………..
Last Name ……………………………… /  Bank Draft
 Telex / Name of Bank …………………………………
Branch …………………………………
Bank Account # …………………………………
First Name ……………………………...
Middle Name (if available) ……………..
Last Name ……………………………… /  Bank Draft
 Telex / Name of Bank …………………………………
Branch …………………………………
Bank Account # …………………………………
First Name ……………………………...
Middle Name (if available) ……………..
Last Name ……………………………… /  Bank Draft
 Telex / Name of Bank …………………………………
Branch …………………………………
Bank Account # …………………………………

Remark : Please note the following

  1. One application form can be used for only one security per closing date.
  2. Substituted payment for dividends will be paid to only NVDR holders who have residence outside Thailand. The NVDR holder whose registered address in Thailand will be paid the substituted payment for dividends in Thai currency only.
  3. Any bank fees incurred from issuing bank draft or transferring money through telex will be deducted from amount of substituted payment for dividends paid to each beneficiary.
  4. The Thai NVDR will pay the substituted payment for dividends only to the beneficiaries who have their names and addresses registered on the book closing date. In case the names which were informed to us in this form are either not correct (i.e. missed or wrong spelling) or not the same as registered in the book closing, the Thai NVDR will pay such substituted payment for dividends only to the persons who have their names registered on the book closing date and with the Thai currency.
  5. If the amount of substituted payment for dividends paid to any beneficiary is not enough for either exchanging to the foreign currency as informed or deducting the bank fees, the Thai NVDR will issue a bank cheque paying such beneficiary in THAI BAHT only.
  6. The Thai NVDR will subsidizes mailing and handling costs of regular registered mail for NVDR holders.

………………………………………….

(Signature of Authorized Person with Company Seal) Name ……………………………………..

Position………………………………………

Department…………………………………..

Date………………………………………….

Please send this application form to : Depository Division

4th Floor, 62 the Stock Exchange of Thailand Building

Ratchadapisek Road, Klongtoey

Bangkok 10110

Telephone (02) 229-2897-9