Name of the Company __________

Registration No. of the Company __________

Address of its Registered Office __________

Nominal Capital __________

Sl. No.

Particulars of shares in respect of which the person whose name is entered in the register of numbers of the company as a holder thereof does not hold the beneficial interest in such shares

Particulars of persons in whose names the above shares have been registered as holders in the register of members

Particulars of persons who hold a beneficial interest in such shares

Nature of the beneficial interest

Dates of declarations under sub-sections (1), (2) and (30 received in respect of the said shares together with names of declarant

Dates of receipt of the said declarations by the company

1

2

3

4

5

6

7

No. of shares

Distinctive Nos. of shares

Name and Nationality

Name and Nationality

Kind of shares

Address

Address

Face value of shares

Father’s/ Husband’s name

Father’s/ Husband’s name

Paid-up value of shares

Date of entry of name in register

Occupation