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If delivering by hand, express mail, courier,
or other expedited service:
American Stock Transfer & Trust Co., LLC
Operations Center Attn: Reorganization Department 6201 15th Avenue Brooklyn, New York 11219 |
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By mail:
American Stock Transfer & Trust Co., LLC
Operations Center Attn: Reorganization Department P.O. BOX 2042 New York, NY 10272-2042 |
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Name(s) and Address of Registered Holder(s)
If there is any error in the name or address
shown below, please make the necessary corrections |
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ADR Number(s)*
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Total Number of
ADSs Represented by ADR(s)* |
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Number of ADSs
Surrendered** |
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Book Entry ADSs
Surrendered |
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TOTAL ADSs
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☐ Check this box if your ADR(s) have been lost, stolen, misplaced or mutilated. See Instruction 5.
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SPECIAL PAYMENT INSTRUCTIONS
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SPECIAL DELIVERY INSTRUCTIONS
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Complete ONLY if the check is to be issued in a name which differs from the name on the surrendered ADR(s). Issue to:
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Complete ONLY if check is to be mailed to some address other than the address reflected above. See Instructions 4. Mail to:
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| | | Name: | | | | | | | | | | | Name: | | | | | |
| | | Address: | | | | | | | | | | | | | | | | |
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(Please also complete IRS Form W-9 on the reverse AND
see instructions regarding signature guarantee. See Instructions 3, 4, 6 and 7) |
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☐
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Please check here if address change is permanent.
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SIGNATURE(S) REQUIRED
Signature(s) of Registered Holder(s) or Agent |
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Must be signed by the registered holder(s) EXACTLY as name(s) appear(s) on ADR(s). If signature is by a trustee, executor, administrator, guardian, attorney-in-fact, officer for a corporation acting in a fiduciary or representative capacity, or other person, please set forth full title. See Instructions 2, 3 and 7.
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Registered Holder
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Registered Holder
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Title, if any
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SIGNATURE(S) GUARANTEED (IF REQUIRED)
See Instruction 3. |
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Unless the ADSs are tendered by the registered holder(s) of the ADS(s), or for the account of a participant in the Securities Transfer Agent’s Medallion Program (“STAMP”), Stock Exchange Medallion Program (“SEMP”) or New York Stock Exchange Medallion Signature Program (“MSP”) (an “Eligible Institution”), the signature(s) must be guaranteed by an Eligible Institution. See Instruction 3.
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Authorized Signature
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Name of Firm
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Address of Firm — Please Print
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