Individual Stockholder

Individual Stockholder Registration Form

Full Name*

First Name *

Middle Name *

Last Name *

Valid Government ID *

Email *

Phone *

Total Number of Shares *

Shares Type *

Stock Certificate Number/s (if certificated shares)

Certification from broker (if uncertificated shares)

Stock Certificate Number/s (if certificated shares) *

Certification from broker (if uncertificated shares) *

Attach Certificate *

Are you going to assign a proxy for the meeting? *

Yes

Proxy Form

Proxy's Full Name *

Proxy's First Name *

Proxy's Middle Name *

Proxy's Last Name *

Proxy's Email *

Proxy's Contact Number *

Proxy's Valid Government ID *