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E-Dividend Mandate Form

SHAREHOLDER REQUEST
Please take this as authority to credit my under-mentioned account(s) with any dividend payment(s) due on my
shareholdings, which are stated below from the date hereof:

Names (in full)

Shareholder Account Number(s)

Contact address

City

Bank Name and Branch

Bank Account Number

Mobile phone number

E-mail address

Shareholders Signature

Date

Bank Authorized signatory

Bank stamp /seal

State

Bank Authorized Signatory

Completed forms should be returned to Diamond Registrars Limited 59, Ogunlana Drive, Surulere, Lagos. For further
information call us on 01-2710574 or email customercare@diamond-registrars.com.

To implement this for your holdings in other companies we manage, kindly tick as appropriate

C&I Leasing Plc

Linkage Assurance Plc

Nigeria Wire Industries Plc

Diamond Bank Plc

Vital Products Plc

For Administrative Use Only: Date received________________


Action taken_________________________________________________________________________
_____________________________________________________

Date________________

Action taken_________________________________________________________________________
_____________________________________________________

Date_______________

[Attach additional documentation, if applicable.]

Diamond Registrars Limited | 59 Ogunlana Drive | Surulere | Lagos | Nigeria


Tel:01-2710574 ;e-mail:customercare@diamond-registrars.com

www.diamond-registrars.com

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