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Number of Shares Owned on the
Record Date
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Number of Shares Subscribed for
Pursuant to Subscription Right
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Number of Shares Subscribed for
Pursuant to Over-Subscription Right
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1.
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2.
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3.
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4.
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Name of Nominee Holder
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DTC Participant Number
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By:
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Name:
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DTC Basic Subscription Confirmation Numbers
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Title:
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Phone Number:
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Fax Number:
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Dated:
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