Annexure_G

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NOMINATION FORM

(Please type this nomination form after carefully reading the notes mentioned below the format)
To,
The Company Secretary,
(Name of the Company )
Address of the Company

I/We, (name of the shareholder(s), hold (Number of shares) Equity shares bearing Distinctive numbers from ______ to _______ of the face value of Rs.__/- each and on which Rs.__/- per share is paid comprised in the Share Certificate No(s). _________. The shares of the following description are standing in my/our name in the Register of Members of the (name of the company).

   Folio No.    Certificate Nos    Distinctive Nos.    Shares covered in each certificate

OR

I/We, (name of the debentureholder(s), hold (Number of debentures) Debentures of the following description in my/our name.

   Folio No.    Debenture Nos.    Distinctive Nos.    Debenture covered in each certificate

OR

I/We, (name of the Fixed Deposit holder(s), hold Fixed Deposit for Rs.______/- of the following description with (name of the company).

   Folio No.    F. D. Receipt Nos     Amount

I/We wish to make a nomination and hereby nominate the following person in whom all rights of transfer and/or amount payable in respect of shares/ debentures/ deposits shall vest in the event of my or our death.

  Sr. No    Name & Address    Age    Relation with Nominator

                Of the Nominee

1.

2.

3.

# The nominee is a minor and his/her date of birth is _________ and the name and address of the guardian is _____________________ .

IN WITNESS WHEREOF I/We, the shareholder(s)/debentureholder(s)/fixed deposit holder(s) herein has/have signed and set my/our hands on this ____ day of _______ 200 .

  Name and address of the Nominator(s)    Signature of the Nominator(s)

  1.
1.

  2.
2.

  3.
3.

  Name and address of Witness    Signature of the Witness

  1.
1.

  2.
2.

Place :

Date :

INSTRUCTIONS

1. Please fill up the details in the form as per your holding. Please do not type this format as it is.

2. The Nomination can be made by individuals only applying/holding shares/ debentures on their own behalf singly or jointly. Non-individuals including society, trust, body corporate, partnership firm, Karta of Hindu Undivided Family, holder of power of attorney cannot nominate. If the shares are held jointly, all joint holders will sign the nomination form.

3. A minor can be nominated by a holder of shares/debentures/deposits and in that event the name and address of the Guardian shall be given by the holder

4. The nominee shall not be a trust, society, body corporate, partnership firm, Karta of Hindu Undivided Family or a Power of Attorney holder. A non-resident Indian can be a nominee on repatriable basis.

5. Nomination stand rescinded upon transfer of share/debenture or repayment/ renewal of deposits made.

6. Transfer of share/debenture in favour of a nominee and repayment of amount of deposit to nominee shall be a valid discharge by a company against the legal heir.

7. The intimation regarding nomination/nomination form shall be filed in duplicate with company/registrar and share transfer agents of the company who will return one copy thereof the share or debenture or deposits holder.