CM 41 Brokers Transfer Form

REPUBLIC OF NAMIBIA Form CM 41

BUSINESS AND INTELLECTUAL PROPERTY AUTHORITY - BIPA

COMPANIES ACT, 2004

(Section 141) (Regulation 58)

BROKER'S TRANSFER FORM

For exchange control purposes

CERTIFICATION BY ISSUER OF SECURITY

A

FULL NAME OF ISSUER OF SECURITY AS SHOWN ON CERTIFICATE

This portion to be completed by the broker

Figures

Words

Quantity and full description of securities

to be transferred

Description

Certificate(s) No.(s)

Certificate and distinctive

numbers(s) (if any)

TRANSFER [in block letters insert the full name(s) of

FROM the present registered holder(s)]

[transferor(s)]

I/We certify that the effective date of the transferor's signature for stamp duty purposes was …………………………………………………………….

……………………………………………………………..

…………………………………………………………….

(Signature of broker)

(Stamp of selling broker)

LODGED FOR CERTIFICATION BY

B

TRANSFER [in block letters insert the full name(s) and the

TO postal address(es) of the person(s) into whose

name(s) the securities are to be transferred]

[transferee(s)] ............................................................................................................................................................. ............................................................................................................................................................. .............................................................................................................................................................

This portion to be competed by the agent of the transferee(s)

CONSIDERATION. - State the amount (in figures) paid for the securities

N$ ........................................................................

I/We request that such entries be made in the register as are necessary to give effect to this transfer.

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Name and address or stamp of person lodging this form or stamp of buying broker (if any)

NAMIBIAN REVENUE STAMPS or endorsement claiming exemption in terms of the Stamp Duties Act, 1993

• FOR USE IN REGISTERING OFFICE

Copyright: Business and Intellectual Property Authority, Namibia