Subscription Form and Power of Attorney

COMPANY LETTERHEAD

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

SUBSCRIPTION FORM AND POWER OF ATTORNEY

I/We, the undersigned, hereby irrevocably apply to subscribe for and agree to take up {{number_of_units}} ({{number_of_units_words}}) of {{type_of_instrument}} (hereinafter referred to as 'the Instruments') in {{company_name}} (hereinafter referred to as 'the Company') at a subscription price of {{currency}} {{price_per_unit}} ({{currency_words}} {{price_per_unit_words}}) per Instrument, for a total consideration of {{currency}} {{total_amount}} ({{currency_words}} {{total_amount_words}}).

SUBSCRIBER DETAILS

Full Name of Subscriber/Entity: {{subscriber_full_name}}

Identification/Registration Number: {{id_registration_number}}

Residential/Registered Address: {{subscriber_address}}

Postal Code: {{subscriber_postal_code}}

Contact Number: {{subscriber_phone}}

Email Address: {{subscriber_email}}

Bank Name: {{subscriber_bank_name}}

Account Number: {{subscriber_bank_account_number}}

Branch Code: {{subscriber_bank_branch_code}}

PAYMENT DETAILS

Payment Method: {{payment_method}}

Payment Reference: {{payment_reference}}

Date of Payment: {{payment_date}}

I/We confirm that payment of the total consideration of {{currency}} {{total_amount}} has been made to the Company's designated bank account as per the payment instructions provided.

POWER OF ATTORNEY

I/We hereby irrevocably nominate, constitute and appoint {{attorney_name}} with powers of substitution, to be my/our true and lawful attorney and agent in my/our name, place and stead, to do, execute and perform all such acts, deeds, matters and things as may be necessary or requisite for the purpose of giving effect to this subscription, including but not limited to:

1. To sign all necessary documents, including share certificates, registers, and other instruments required for the allotment and registration of the Instruments.

2. To make any necessary declarations or statements on my/our behalf.

3. To attend to all formalities with any regulatory body or authority regarding the subscription and registration of the Instruments.

4. To receive and accept any documents, notices or communications relating to the Instruments on my/our behalf.

This Power of Attorney shall be valid and binding from the date of signature hereto and shall remain in full force and effect until the completion of all acts necessary for the finalisation of this subscription.

UNDERTAKINGS AND WARRANTIES

I/We hereby warrant that I/we have full legal capacity and authority to enter into this Subscription Form and Power of Attorney.

I/We confirm that I/we have received, read and understood the terms and conditions relating to the subscription of the Instruments, including any accompanying prospectus or offering circular.

I/We indemnify the Company against any claims, losses, damages or expenses arising from any misrepresentation or breach of these undertakings and warranties.

GOVERNING LAW

This Subscription Form and Power of Attorney shall be governed by and construed in accordance with the laws of {{governing_country}}.

SIGNATURE BLOCK

___________________________

Signature of Subscriber/Authorised Signatory

Name: {{signer_name}}

Capacity (if applicable): {{signer_capacity}}

Date: {{signature_date}}

Place: {{signature_place}}

WITNESS 1:

___________________________

Name: {{witness1_name}}

Date: {{witness1_date}}

WITNESS 2:

___________________________

Name: {{witness2_name}}

Date: {{witness2_date}}