IPO Application Form Sample

“Interested persons are entitled to a prospectus, if they desire, and that copies of prospectus may be obtained from the issuer and the issue managers.”

APPLICATION FROM

GRAMEENPHONE LTD. APPLICATION FOR SHARES BY INVESTORS OTHER THAN NON-RESIDENT BANGLADESHI(S)

Warning: Please read the instructions at the back of this form. Incorrectly filled applications or applications failing to comply with any of the instructions therein may be rejected. Bankers Sl. No.

The Chief Executive Officer 

GRAMEENPHONE LTD.

Brokers Sl. No.

Celebration Point, Plot 3 & 5, Road 113/A, Gulshan-2, Dhaka-1212, Bangladesh.

Dear Sir , I/We apply for and request you to allot me/us the 200 number of ordinary Shares and I/We agree to accept the same or any smaller number that may be allotted to me/us upon the terms of the Company’s Prospectus approved by the Securities and Exchange Commission and Subject to the Memorandum and Articles of Association of the Company. Further, I/We authorize you to place my/our name(s) on the Register of Members of the Company and deposit the said ordinary shares in my Beneficiary Owner (“BO”) account; I/we further authorize you to send a crossed (Account Payee only) cheque in respect of any application money refundable to me /us by post/courier at my/our risk to the first applicant’s address stated  below: 1. No. of Ordinary Shares 200 of Tk. 10/- each per value at an Issue Price of Tk. 70/-per share (including a premium of Tk. 60.00 per share).

2. Total subscription money of the amount of Tk (in Figure) 14,000/= Taka. (in words) FOURTEEN THOUSAND only depositedvide Cash/Cheque/Draft/PayO Cash/Cheque/Draft/PayOrderNo……………………………..Dated………………………….…0n rderNo……………………………..Dated………………………….…0n …………………..……..Bank ………............................….Branch…………………………………………………….. 3.Beneficiary Owner (B/O) Account Number 

1

2

0

3

2

1

0

0

0

7

2

2

4

2

1

1

(If you do not mention your valid BO account number, your application will be treated as invalid)

4. I/We agree to fully abide by the instruction given herein. 5. Particulars of Applicant(s): a) Sole/First Applicant Name :Mr./Mrs./Ms. FERDOUSI BEGUM Father’s/ Husband ‘s Name: LATE AZIZ AHMED AHMED Mother’s Name : ANOWARA BEGUM Postal Address: 244/1/A. NORTH GORAN, KHILGAON SHEPAHIBAG (3RD FLOOR), DHAKA-1219. Telephone No. (If any): 01552-369973 Occupation: HOUSE WIFE Nationality:  BANGLA  BANGLADESH DESHI  I  For Refund Warrant: Applicant’s Bank A/C No: 4010 - 063525- 300 Name of the Bank: AB BANK LIMITED Branch: NORTH SOUTH ROAD b) Second Applicant Name: Mr./Mrs./Ms. Father’s/Husband’s Father’s/Husband’s Name: Mother’s Name: Postal Address:

N/A

Occupation:

Nationality:  BANGLAD  BANGLADESHI  ESHI 

6. I/We hereby declare that I/We have read the Prospectus of  GRAMEENPHONE LTD. And have willingly subscribed for 200 ordinary shares of Tk 10/- each par value at an Issue Price of Tk. 70.00 per share (including a premium of Tk. 60.00 per share) on this form.

7.Specimen Signature(s):

(¡) Name (in Block Letters) (¡¡) Name (in Block Letters)

FERDOUSI BEGUM

Signature: Signature:

BANKER’S ACKNOWLEDGEMENT

Certified that this Bank has received Tk.(in figure) 14,000/= (in word FOURTEEN THOUSAND Only from Mr./Mrs./Ms.  being FERDOUSI BEGUM the applications money for  200 of Ordinary Shares of  GRAMEENPHONE GRAMEENPHONE LTD. Banker’s Sl.No. ……….

Seal and Date

Authorized Signature (Name & Designation)

“Interested persons are entitled to a prospectus, if they desire, and that copies of prospectus may be obtained from the issuer and the issue managers.”

APPLICATION FROM

GRAMEENPHONE LTD. APPLICATION FOR SHARES BY INVESTORS OTHER THAN NON-RESIDENT BANGLADESHI(S)

Warning: Please read the instructions at the back of this form. Incorrectly filled applications or applications failing to comply with any of the instructions therein may be rejected. The Chief Executive Officer 

GRAMEENPHONE LTD. Celebration Point, Plot 3 & 5, Road 113/A, Gulshan-2, Dhaka-1212, Bangladesh.

Bankers Sl. No. Dear Sir , I/We apply for and request you to allot me/us the 200 number of ordinary Shares and I/We agree to Brokers Sl. No. accept the same or any smaller number that may be allotted to me/us upon the terms of the Company’s Prospectus approved by the Securities and Exchange Commission and Subject to the Memorandum and Articles of Association of the Company. Further, I/We authorize you to place my/our name(s) on the Register of Members of the Company and deposit the said ordinary shares in my Beneficiary Owner (“BO”) account; I/we further authorize you to send a crossed (Account Payee only) cheque in respect of any application money refundable to me /us by post/courier at my/our risk to the first applicant’s address stated below: 1. No. of Ordinary Shares 200 of Tk. 10/- each per value at an Issue Price of Tk. 70/-per share (including a premium of Tk. 60.00 per share).

2. Total subscription money of the amount of Tk (in Figure) 14,000/= Taka. (in words) FOURTEEN THOUSAND only depositedvide Cash/Cheque/Draft/PayOrderNo……………………………..Dated………………………….…0n …………………..……..Bank ………............................….Branch…………………………………………………….. 3.Beneficiary Owner (B/O) Account  Number 

1

2

0

3

2

1

0

0

1

2

2

7

4

3

5

1

(If you do not mention your valid BO(Beneficiary Owners) account, your application will be treated as invalid)

4. I/We agree to fully abide by the instruction given herein. 5. Particulars of Applicant(s): a) Sole/First Applicant Name :Mr./Mrs./Ms. FERDOUSI BEGUM Father’s/Husband ‘s Name: LATE AZIZ AHMED Mother’s Name : ANOWARA BEGUM Postal Address: 244/1/A. NORTH GORAN, KHILGAON SHEPAHIBAG (3RD FLOOR), DHAKA-1219. Telephone No. (If any): 01552-369973 Occupation: HOUSE WIFE Nationality:  BANGLADESHI  For Refund Warrant: Applicant’s Bank A/C No: 4010 -063525- 300 Name of the Bank: AB BANK LIMITED Branch: NORTH SOUTH ROAD b) Second Applicant: Mr./Mrs./Ms. IFTEKHAR UDDIN Father’s/Husband’s Name: MD. KUTUB UDDIN Mother’s Name: MRS. FERDOUSI BEGUM Postal Address: 244/1/A.NORTH GORAN, KHILGAON SHEPAHIBAG (3RD FLOOR),DHAKA-1219.

Occupation:

SERVICE

Nationality:  BANGLADESHI 

6. I/We hereby declare that I/We have read the Prospectus of  GRAMEENPHONE LTD. And have willingly subscribed for 200 ordinary shares of Tk 10/- each par value at an Issue Price of Tk. 70.00 per share (including a premium of Tk. 60.00 per share) on this form.

7.Specimen Signature(s):

(¡) Name (in Block Letters) (¡¡) Name (in Block Letters)

FERDOUSI BEGUM

Signature:

IFTEKHAR UDDIN

Signature:

BANKER’S ACKNOWLEDGEMENT

Certified that this Bank has received Tk.(in figure) 14,000/= (in word FOURTEEN THOUSAND Only from FERDOUSI BEGUM Mr./Mrs./Ms.  being the applications money for  200 of Ordinary Shares of  GRAMEENPHONE LTD. Banker’s Sl.No. ……….

Seal and Date

Authorized Signature (Name & Designation)

“Interested persons are entitled to a prospectus, if they desire, and that copies of prospectus may be obtained from the issuer and the issue managers.”

APPLICATION FROM

GRAMEENPHONE LTD.

APPLICATION FOR SHARES BY INVESTORS OTHER THAN NON-RESIDENT BANGLADESHI(S)

Warning: Please read the instructions at the back of this form. Incorrectly filled applications or applications failing to comply with any of the instructions therein may be rejected. The Chief Executive Officer 

GRAMEENPHONE LTD. Celebration Point, Plot 3 & 5, Road 113/A, Gulshan-2, Dhaka-1212, Bangladesh.

Dear Sir , I/We apply for and request you to allot me/us the 200 number of ordinary Shares and I/We agree to accept the same or any smaller number that may be allotted to me/us upon the terms of the Company’s Prospectus approved by the Securities and Exchange Commission and Subject to the Memorandum and Articles of Association of the Company. Further, I/We authorize you to place my/our name(s) on the Register of Members of the Company and deposit the said ordinary shares in my Beneficiary Owner (“BO”) account; I/we further authorize you to send a crossed (Account Payee only) cheque in respect of any application money refundable to me /us by post/courier at my/our risk to the first applicant’s address stated  below: Bankers Sl. No. 1. No. of Ordinary Shares 200 of Tk. 10/- each per value at an Issue Price of Tk. 70/-per share Brokers Sl. No. (including a premium of Tk. 60.00 per share).

2. Total subscription money of the amount of Tk (in Figure) 14,000/= Taka. (in words) FOURTEEN THOUSAND only depositedvide Cash/Cheque/Draft/PayOrderNo……………………………..Dated………………………….…0n ………………….. ……..Bank ………............................….Branch…………………………………………………….. 3. Beneficiary Owner (B/O) Accoun Number 

1

2

0

3

2

1

0

0

0

7

2

2

4

3

5

1

(If you do not mention your valid BO(Beneficiary Owners) account, your application will be treated as invalid)

4. I/We agree to fully abide by the instruction given herein. 5. Particulars of Applicant(s): a) Sole/First Applicant Name :Mr./Mrs./Ms. IFTEKHAR UDDIN Father’s/Husband ‘s Name: MD. KUTUB UDDIN Mother’s Name : FERDOUSI BEGUM Postal Address: 244/1/A. NORTH GORAN, KHILGAON SHEPAHIBAG (3RD FLOOR), DHAKA-1219. Telephone No. (If any): 01711-081159 Occupation: SERVICE Nationality:  BANGLADESHI  For Refund Warrant: Applicant’s Bank A/C No: 4010 - 063525- 300 Name of the Bank: AB BANK LIMITED Branch: NORTH SOUTH ROAD b) Second Applicant: Mr./Mrs./Ms. Father’s/Husband’s Name: Mother’s Name: Postal Address:

N/A

Occupation:

Nationality:  BANGLADESHI 

6. I/We hereby declare that I/We have read the Prospectus of  GRAMEENPHONE LTD. And have willingly subscribed for 200 ordinary shares of Tk 10/- each par value at an Issue Price of Tk. 70.00 per share (including a premium of Tk. 60.00 per share) on this form.

7.Specimen Signature(s):

(¡) Name (in Block Letters) (¡¡) Name (in Block Letters)

IFTEKHAR UDDIN

Signature: Signature:

BANKER’S ACKNOWLEDGEMENT

Certified that this Bank has received Tk.(in figure) 14,000/= (in word FOURTEEN THOUSAND Only from FERDOUSI BEGUM Mr./Mrs./Ms.  being the applications money for  200 of Ordinary Shares of  GRAMEENPHONE LTD. Banker’s Sl.No. ……….

Seal and Date

Authorized Signature (Name & Designation)