Certificate counterfoil and share certificate issue register

Certificate No.

[____]

Folio No.

[____]

Name of holder

[____________________]

Class of security

[Equity / ____ Preference / Debenture Series ____]

No. of securities

[______]

Distinctive nos.

[______] to [______]

Nominal value per unit

Rs [___]

Amount paid up per unit

Rs [___]

Issue price per unit

Rs [___]

Securities premium per unit

Rs [___]

Ground of issue

[Subscription to memorandum / Allotment on ____ / Transfer registered on ____ / Transmission / Bonus / ESOP exercise / Conversion / Duplicate in lieu of Certificate No. ____]

Board resolution dated

[DD.MM.YYYY]

Date of issue

[DD.MM.YYYY]

Stamp duty paid

Rs [______]

Challan / SRN

[__________]

Entered in the Register of Members at page / folio

[____] on [DD.MM.YYYY]

Certificate delivered to the holder on

[DD.MM.YYYY], by [hand against acknowledgement / registered post / courier AWB no. ____]

Signature of the authorised signatory

[Sd/-]