FORM II : Declaration to be made by a person referred to in sub-section (2) or sub-section (3) of section 187C of the Companies Act, 1956 (1 of 1956)

[See rule 3(2)]

To

___________________________

(Name of the company)

___________________________

(Address of the registered office)

In pursuance of sub-section (2)/sub-section (3) of section 187C of the Companies Act, 1956 (1 of 1956), I hereby declare that I hold/have obtained the beneficial interest in _________________________________________ shares bearing Nos. _____________ and (number) (kind)

specify the following particulars, namely:

2. Date of allotment/transfer of the shares in the name of the person or persons referred to above:

3. Date of acquisition of the beneficial interest:

4. Particulars of the person from whom the beneficial interest is acquired; if the transferor of the beneficial interest is also a person who held only a beneficial interest, state whether any declaration under sub-section (2) of section 187C had been made by him to the company. If so, the date of the declaration(s) made by him:

5. Nature of the beneficial interest:

6. Circumstances under which the shares were not registered in my name:

Place ___________

Date ___________    

__________________________

Signature of the person making the declaration

____________________________

Name and address     

CERTIFICATE

I hereby certify that the beneficial interest in the shares mentioned above has been transferred by me on _____________________________

                    (date)

_______________________________________

Signature of the person who has transferred the

beneficial interest in the shares

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