“Application Form for PRVATE PLACEMENT Pease read carci he nsvucton onthe reverse) TOWN BENEFIT FUND (KUMBAKONAWM) LIMITED Bree ie ieecaal ea Acre ace) ant Road, KUMBAKONAM - 612 001. Ph.2431918 the Companies Act, 1956) To THE BOARD OF DIRECTORS, ‘Town Benofit Fund (Kumbakonam) Limited, ‘Braich Kumbakonam - 612 001. Sir, | We hereby apply to you for allotment to me /us of the Equity Share(s) stated below. | We hereby agree to accept subjectto the terms of application form, Memorandum and Aticles of Association ofthe company. | We note thatthe Board of Directors are entiledin their absolute discretion to accept or reject this application form in whole orin part without assigning any reason whatsoever. Note : Please use BLOCK LETTERS in English, Date E-Mail. ID. Number of Shares applied [Amount in Figures | z, [Amount in words (Cash / Cheque / Draft No. Dated [Drawn on (Name of Bank) Sole / FIRST APPLICANT Mr. / Mrs. / Miss : Address in Full : STREET TOWNICITY : DISTRICT Occupation Father / Husband Name Mobile / Telephone No. Signature SECOND APPLICANT Mr. Mrs. / Miss : Addiees I PUN’: “STREED °° inet 30 aoe nig Male es TOWNICITY : DISTRICT Pin Code ‘Occupation Father / Husband Name Mobile / Telephone No. Signature Name of the Nominee (ff any) |Mr. / Mrs. / Miss. Relationship [Date of Birth (Minor SPECIMEN SIGNATURE(S) Sole first Applicant 4 Second Applicant 2