CRYSTO GRAPHITES PVT. LTD.

Manufacturer of Natural Crystalline Graphite Powder & Flakes

VIP Plot No-130, Ekamra Vihar, IRC Village, Nayapali,
Bhubaneswar, State- Orissa, India -751015
Crysto Graphites
Pvt. Ltd. Phone No- 0674-2550681, 6547968, Mob- 9238377968, Fax-0674-2550681
Email .ID info@crystographites.com

APPLICATION FOR ALLOTMENT OF PREFERENCE SHARES

Date:

To
The Board of Directors
………………………………..
……………………………….
…………………………..

Dear Sirs,

 I/We hereby apply for allotment of the 13% Preference Shares mentioned herein below.

 The amount payable on application as shown below is remitted herewith.

 I/we hereby agree to accept the Preference Shares applied for, or such lesser number as may
be allotted to me/us subject to the term mentioned overleaf and the Memorandum and Article
of the Company.

 I/We understand that I/We shall sign such other documents and do all such acts, if any,
necessary on my/our part, to enable me/us to be registered as the holder (s) of Preference
Shares in respect to which this application may be accepted.

 I/we agree to accept the shares subject to laws as applicable, guidelines, notifications and
regulations relating to the issue of capital and listing of securities issued from time to time by
SEBI / Government of India / RBI or other authorities.

 I/we hereby solemnly declare that I am/we are not applying the Preference Shares in
contravention of Section 269 SS of the Income Tax Act, 1961.

 I/we hereby solemnly declare that I am/we are not applying the Preference Shares in
contravention of Section 68A of the Companies Act, 1956.

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I/we give below the following particulars for your information

Date : ______________

In figures In words

Number of shares applied for

Payment Details (Rs. In figures ) (Rs.In words)
Number of shares applied for

Amount Per Share

(i.e. face value of the share )

Premium, if any

Total Amount

Cheque/Draft/TT No. & Dated

Drawn on

Investment for the period 1 2 3 4 5 6 7

(1) Sole/First Applicant; Name Surname

Name in Full

Father’s Name/Husband

Address :

Occupation: Age :

Nationality :

PAN No. :

Income Tax Circle / Word/Dist.

Usual Signature

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(2) Second Applicant Name Surname
Name in Full

Father’s Name/Husband

Address :

Occupation : Age :

Nationality :

PAN No. :

Income Tax Circle / Word/Dist.

Usual Signature

(3) Third Applicant Name Surname

Name in Full

Father’s Name/Husband

Address :

Occupation : Age :

Nationality :

PAN No. :

Income Tax Circle / Word/Dist.

Usual Signature

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Sole /first Applicant’s Bank Details (For Dividend)
Bank Name

Branch / Address

City

Type of Account (please specify)

Account No.

MICR Code of the Bank

Details of Nominee :
Name

Address

Date of Birth (if minor)

Name of Guardian

Signature of the Nominee

Specimen Signature 1st Applicant

1st Applicant 2nd Applicant 3rd Applicant

Crysto Graphites Pvt.Ltd.

Plot no 130, VIP Area, Ekamra Vihar, IRC Village, Nayapalli, Bhubaneswar.
State- Orissa, India-751015

Acknowledgement Slip

Received from ______________________________ an application for _______

Preference shares of Rs. 10/- each for cash at a premium of Rs._______ per share

along with cash/cheque/draft/TT No. __________ for Rs. __________/- dated

_______ drawn on ____________________, Branch being the application payable

thereon.

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 INSTRUCTIONS

1. Application must be completed in Block letters in English, if not complete in every respect,
are liable to be rejected.

2. Signature should be any one of the following languages namely English or Hindi. Signatures
in languages other than those, including thumb impression must be attested by a Magistrate
under his official seal.

3. In the case of an application signed under a Power of Attorney, the relevant of Attorney or
other authority as the case may be or a certified copy thereof must be registration along
with the application or ledged separately at the Registered Office of the Company.

4. Cheques/Bank Drafts should be crossed “Account Payee Only” and made payable to
“CRYSTO GRAPHITES PVT. LTD.” at Bhubaneswar

5. The Board of Directors reserves the right to accept or reject any application in whole or in
part without assigning any reason. Whereas applications are rejected in full or no share
allotted against it the whole of the application money will be refunded to the applicant.

6. In case application is for shares of total nominal value of Rs. 50,000/- or more then
Permanent Account Number allotted under the Income Tax Act, 1961 should be mentioned in
the relevant column in the application. In case, the PAN has not been allotted, the
applicant should mention “not allotted”. Application forms without this information will be
considered incomplete and are liable to be rejected. Please enclose copy of PAN Card.

7. The Application is meant only for use by the Residential Indian.

8. Attention of applicants is drawn to sub-section (i) of Section 68A of the Companies Act,
1956, which is reproduced below :

Any person who :

a. Makes in a fictitious name, an application to a company for acquiring or subscribing for

any shares therein of

b. Otherwise induces a company to allot, or register any transfer of shares therein to

him, or to any other person in a fictitious name, shall be punished with
imprisonment for a term which may extend to five years.