| 1. |
Date
of change of [Select Option]: |
|
| 2. |
Name
of Registered Holder: |
[Select Option] |
| 3. |
Circumstance(s)
giving rise to the interest or change in interest: |
|
| # Please
specify details |
|
| 4. |
Information
relating to shares held in the name of the Registered
Holder: |
| No. of Shares
held before the change: |
|
| As a percentage
of issued share capital: |
% |
| No. of N.A. which
are subject of this notice: |
|
| As a percentage
of issued share capital: |
% |
| Amount of consideration
(excluding brokerage and stamp duties) per share
paid or received: |
|
| No. of N.A. held
after the change: |
|
| As a percentage
of issued share capital: |
% |