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By Mail:
Citibank, N.A. c/o Voluntary Corporate Actions P.O. Box 43011 Providence, RI 02940-3011 |
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By Overnight Courier:
Citibank, N.A. c/o Voluntary Corporate Actions 150 Royall Street, Suite V Canton, MA 02021 |
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ITEM A:
DESCRIPTION OF ADSs TENDERED
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Names(s) and Address(es) of
Registered ADS Holder(s)* |
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ADSs Tendered
(Attach additional signed list if necessary) |
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Total Number of ADSs held in
Book-Entry Form** |
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Number
of ADSs Tendered*** |
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Total ADSs
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ITEM A:
DESCRIPTION OF ADSs TENDERED
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Names(s) and Address(es) of
Registered Holder(s)* |
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ADSs Tendered
(Attach additional signed list if necessary) |
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Total Number of ADSs held in
Book-Entry Form** |
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Number
of ADSs Tendered*** |
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ITEM B: SPECIAL PAYMENT
INSTRUCTIONS
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| | | To be completed ONLY if the check for the purchase price for ADSs accepted for payment (less any applicable withholding taxes and without interest, and less a cash distribution fee of $0.05 per tendered ADS accepted for purchase in the Offer that will be paid to Citibank, N.A., as ADS Depositary) is to be issued in the name of someone other than the person(s) specified in Item A. See Instruction 1, 4, 5 and 6. | | |
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Issue the check which I am entitled to receive to:
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Name
(Please Type or Print)
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Address
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(Include Zip Code)
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(Taxpayer Identification or Social Security Number)
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ITEM C: SPECIAL DELIVERY
INSTRUCTIONS
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| | | To be completed ONLY if delivery of the check (less any applicable withholding taxes and without interest, and less a cash distribution fee of $0.05 per tendered ADS accepted for purchase in the Offer that will be paid to Citibank, N.A., as ADS Depositary) is to be made to an address other than that specified in Item A, or to an address other than that appearing in Item B (if filled in). See Instruction 1, 4, 5 and 6. | | |
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Deliver the check which I am entitled to receive to:
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Name
(Please Type or Print)
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Address
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(Include Zip Code)
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(Taxpayer Identification or Social Security Number)
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| | Signature of Owner(s): | | |
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Signature(s) of Owner(s):
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| | Dated: | | |
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| | (Must be signed by registered holder(s) exactly as name(s) appear(s) on a security position listing or by person(s) authorized to become registered holder(s) ADSs as evidenced by endorsement or stock powers transmitted herewith. If signed by a trustee, executor, administrator, guardian, attorney-in-fact, officer of a corporation or other person acting in a fiduciary or representative capacity, the full title of the person should be set forth. See Instruction 4). | | |||
| | Name(s): | | |
(Please Print)
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| | Capacity (full title): | | |
(Please Print)
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| | Address: | | |
(Include Zip Code)
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| | Daytime Area Code and Telephone Number: | | |
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| | Taxpayer Identification or Social Security No.: | | |
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| | Name of Firm: | | |
(Please Print)
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| | Address: | | |
(Include Zip Code)
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| | Authorized Signature: | | |
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| | Name: | | |
(Please Print)
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Area Code and Telephone Number:
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| | Dated: | | |
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