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Request For Issue of Replacement

Request for issue of replacement

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Haus Mädchen
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© © All Rights Reserved
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15 views

Request For Issue of Replacement

Request for issue of replacement

Uploaded by

Haus Mädchen
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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請用英文正楷填寫

TO BE COMPLETED IN BLOCK LETTERS


補發申請書
REQUEST FOR ISSUE OF REPLACEMENT(S)
本表格可以郵寄、
本表格可以郵寄、傳真或送交本公司。
傳真或送交本公司。
THIS FORM CAN BE RETURNED BY MAIL / BY FAX / BY HAND.
致: 香港中央證券登記有限公司 / 香港證券登記有限公司
To: COMPUTERSHARE HONG KONG INVESTOR SERVICES LIMITED / HONG KONG REGISTRARS LIMITED
香港灣仔皇后大道東 183 號合和中心 17M 樓
17M Floor, Hopewell Centre, 183 Queen's Road East, Wan Chai, Hong Kong
顧客服務熱線 Customer Services Hotline: (852) 2862 8555 圖文傳真 Fax: (852) 2865 0990 / 2529 6087

日期 本公司專用欄
SRN
Date FOR OFFICE USE

股票名稱 Name of Company HSBC

甲 部 : 申 請 人 資 料 SECTION A : PARTICULARS OF CLAIMANT


申請人姓名 Name of Claimant
地址 Address

電話 / 圖文傳真 號碼Telephone / Fax No(s).


乙 部 : 申 請 補 發 之 證 書 SECTION B : CERTIFICATE(S) TO BE REPLACED
請說明申請補發證書的類別： 股份/認股權證/基金數目
Please specify the details of certificates to be replaced: No. of shares/warrants/units

(如普通股份，2002年度紅股，2002年度以股代息，公開發售股份等)
(e.g. Ordinary Shares, 2002 Bonus, 2002 Scrip Dividend, Public Offer Shares, etc.)

未收到/遺失的證書號碼(如知悉)：Certificate no(s). not received / lost (if known):

倘若未能提供未收到/遺失的證書號碼，請列出手上持有之證書號碼，以便查核紀錄：
If you are unable to provide the certificate no(s). which has / have not been received / lost, please list the certificate
no(s). still in your possession for investigation:
Please see attachment
丙部:申請補發之股息/退款支票
SECTION C : DIVIDEND / REFUND CHEQUE(S) TO BE REPLACED
請說明申請補發股息 / 退款支票的資料：
Please specify the details of dividend / refund cheques to be replaced:

(請註明年份或期數，如2002年度末期息，公開發售退款等 Please specify year of dividend(s), e.g. 2002 Final Dividend, Public Offer Refund, etc.)

丁 部 : 聲 明（請 於 適 當 的 空 格 內 加 上 √ ）
SECTION D : DECLARATION (Please √ where appropriate)
本人謹此聲明  尚未收到 /  遺失上述項目並要求辦理補發事宜。本人承諾若日後收回或尋獲上述項目時當即送
交貴處註銷。
I hereby declare that I have  not received /  lost the above item(s) and request the issue of replacement(s). I
undertake to return the said item(s) for cancellation immediately should it/they be subsequently received or found.
請以下述語言回覆：
請以下述語言回覆：
I would like to receive your reply in the following language:

申請人簽署 Signature(s) of Claimant(s)  中文  English


備註: 所有聯名證券持有人均須簽署。除本表格所要求提供的資料外，恕不接受其他額外指示。
N.B. All joint securities holders must sign. Any instructions written on this Form (other than those asked for herein) will not be processed.

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