8/9/2019 AFCL Other Form

1/3

INTERESTED PERSONS ARE ENTITLED TO A PROSPECTUS, IF THEY SO DESIRE, AND THAT COPIES OF PROSPECTUS MAYBE OBTAINED FROM THE ISSUER AND THE ISSUE MANAGER.

Active Fine Chemicals LimitedAPPLICATION FORM

APPLICATION FOR SHARES BY INVESTORS OTHER THAN NON-RESIDENT BANGLADESHI (S)

Warning : Please read the instruction at the back of this form

. Incorrectly filled application may be rejected.

The Managing DirectorActive Fine Chemicals LtdTanaka Tower (2nd Floor),42/1/Gha, Segun Bagicha,Dhaka-1000, Bangladesh

Dear Sir,I/we apply for and request you to allot me/us the 500 number of Shares and I/we agree to accept the same or any smaller number that may be allotted to me/us upon the terms of the companys approved Prospectus and subject to the Memorandum and Articles of Association of the company. Further, I/weauthorize you to place my/our name(s) on the Register of Members of the company and deposit the said shares to my BO ( Beneficiary Owner) Accountand/or Crossed (Account Payee only) cheque in respect of any application money refundable by post/courier at my/our risk to the first applicants addressstated below:1. No. Ordinary shares 500 of Tk.10 each.2. Amount of Tk. (in figure): 5000/-, Taka (in words): Five Thousand Only.

only deposited vide Cash/ Cheque/ draft/ pay Order NoDated..on. Bank..Branch.

3. Depository (B/O) Account Number

(If you do not mention your valid BO (Beneficiary Owners) account, your application will be treated as in valid)4. I/we agree to fully abide by the instruction given herein.5. Particulars of Applicant(s):

a) Sole/First ApplicantName:

Fathers / Husband name:

Mothers name:

Postal Address:

Occupation: Nationality: Telephone No.(if any):

For refund warrant (Application will not be treated as valid if anyone uses a non-scheduled bank. To avoid this complication, investors arerequested not to use the name of any non-scheduled bank) Please write the correct and full name of bank and branch.

For refund purpose: I/we wants refund through Bank Account* Hand delivery/Courier(please put tick marks inwhich refund will be made)The applicant shall provide with the same Bank Account number in the application form as it is in the BO account of the applicant. Otherwisethe application will be considered invalid and the subscription money may be forfeited.

Applicants Bank A/C No:

Name of the Bank:

b) Second ApplicantName:Fathers / Husband name:Mothers name:Postal Address:Occupation: Nationality: Telephone No.(If any):

6. I/we hereby declare that I/we have read the Prospectus ofActive Fine Chemicals Limited and have willingly subscribed for 500 no. of shares of Tk10.00each.3. Specimen Signature(s):

(i) Name ( in block letters): Signature:(ii) Name ( in block letters): Signature:

*In case of deposit into the applicants bank account, the applicant will bear the applicable charge, If any, of the applicants banker, and the issuer shallsimultaneously issue a letter of intimation to the applicant containing, among others, the date and amount remitted with details of the bank through and towhich bank such remittance has been effected... .. .. .. .. .. .. .. .. .. .. .. .. ... .. .. .. .. .. .. ... .. .. .. .. .. .. .. .. .. .. .. .. .. ... .. .. .. .. .. .. ....................................................................................................................................................

BANKERS ACKNOWLEDGEMENTCertified that this Bank has received Tk5000/-(in word) Five Thousand only form Mr./Mrs./Msbeing theapplication money for ..nos. of Ordinary Shares of Active Fine Chemicals Ltd.

Bankers Sl. No. Seal and Date Authorized Signature

(Name & Designation)

Bankers Sl. No.

8/9/2019 AFCL Other Form

2/3

INSTRUCTIONS

1. As per provision of Depository Act, 1999 and regulations made there under shares will only be issued in dematerialized condition. Please mentionyour BO (Beneficiary Owner) Account number in the application form. If you do not mention your valid BO (Beneficiary Owner) Account, yourapplication will be treated as invalid.

2. All information must be typed or written in full (in Block letters) in English or in Bengali and must not be abbreviated.

3. Application must be made on the Companys printed form/photocopy or typed copy/hand written form thereof.

4. Application must not be for less than 500 Ordinary Shares and must be for a multiple of 500 Ordinary Shares. Any Application not meeting this criterion willnot be considered for allotment purpose.

5. Remittance for the full amount of the Shares must accompany each Application and must be forwarded to any of the Bankers to the Issue. Remittanceshould be in the form of Cash/ Cheque/ Bank Draft/ Pay Order payable to one of the Bankers to the Issue A/C Active Fine Chemicals Limited andcrossed A/C Payee only and must be drawn on a Bank in the same town as the Bank to which the Application form has been sent.

6. In the case of Joint Application Form, the Allotment Letter will be dispatched to the person whose name appears first on this Application Form.

7. Joint Application form for more than two persons will not be accepted. In case of joint Application, each party must sign the Application Form.

8. Application must be in full name of individuals or companies or societies or trusts and not in the name of firms, minors or persons of unsound mind.Application from financial and market intermediary companies and Private Company must be accompanied by Memorandum and Articles of Association and

Certificate of Incorporation.

9. An applicant can not submit more than two applications, one in his/her own name and another jointly with another person. Incase an applicant makes more than two applications, all applications will be treated as invalid and will not be considered for allotmentpurpose. In addition, whole or part of application money may be forfeited by the Commission.

10. No receipt will be issued for the payment made with Application, but the bankers will issue a provisional acknowledgment to the Issue forApplication lodged with them.

11. In the case of non-allotment of securities, if the applicants bank accounts as mentioned in their IPO Application Forms are maintained with the Bankersto the Issue, refund amount of those applicants will be directly credited in to the respective bank account as mentioned in their IPO Application Forms.Otherwise, refund will be made only through Account Payee cheque(s) showing bank account number and name of bank and branch as mentioned in theApplication payable at Dhaka or Chittagong, as the case may be.

12. Allotment will be made solely in accordance with the instructions of the Securities and Exchange Commission (SEC).

13. Making of any false statement in the application or supplying of incorrect information therein or suppressing any relevant information

shall make the application liable to rejection and subject to forfeiture of application money and /or forfeiture of share (unit) before or afterissuance of the same by the issuer. The said forfeited Application money or share (unit) will be deposited in account specified by theSecurities and Exchange Commission (SEC). This may be in addition to any other penalties as may be provided for by the law.

14. Applications, which do not meet the above requirements, or applications, which are incomplete, shall not be considered for allotment purpose.

15. The Bankers to the Issue Banks shall be obliged to receive the A/C Payee Cheque(s) on the closing day of the subscription of the IPO.

16. No sale of securities shall be made, nor shall any money be taken from any person, in connection with such sale until 25(twenty five) days afterthe prospectus has been published.

53

8/9/2019 AFCL Other Form

3/3

BANKERS TO THE ISSUEJanata Bank Ltd.1. Kamal Attatuk Avenue Branch, Dhaka2. Dhanmondi Branch, Dhaka3. Elephant Road Branch, Dhaka

4. Gulshan Branch, Dhaka5. Uttara Model Town Corporate Branch,Dhaka6. Mohakhali Corporate Branch, Dhaka7. Shantinagar Branch, Dhaka10. Motijheel Corporate Branch, Dhaka8. Dhaka University Campus Branch, Dhaka9. Rajarbag Corporate Branch, Dhaka11. B.B Road Corporate Branch, Dhaka12. Khulna Corporate Branch, Khulna13. Sheikh Mujib Road Corporate Branch,Chittagong14.Potia Branch, Chittagong15. Rajsgahi Corporate Branch, Rajshahi16. Comilla Corporate Branch, Comilla

Southeast Bank Ltd.1. Principal Br. Dhaka2. Corporate Br. Dhaka3. Dhanmondi Br. Dhaka4. Uttara Br. Dhaka5. New Elephant Road Br. Dhaka6. Gulshan Br. Dhaka7. Kakrail Br. Dhaka8. New Eskaton Br. Dhaka9. Agargaon Br. Dhaka10. Motijheel Br. Dhaka11. Shyamoli Br. Dhaka12. Kawran Bazar Br. Dhaka13.Satmashjid Road Branch, Dhaka14.Bandar Bazar Br. Sylhet15.Moulvibazar Br. Moulvibazar16.Agrabad Br. Chittagong

17. Khatunganj Br. Chittagong18. Jubilee Road Br. Chittagong19.Halishahar Br. Chittagong20. Coxs Bazar Br. Coxs Bazar21.Feni Br. Feni22. Bogra Br. Bogra23.Khulna Br. Khulna.24.Barisal Branch.25. Rajshahi Branch, Rajshahi.NCC Bank Ltd.1. Motijheel Branch ,Dhaka2. Kawran Bazar Branch,Dhaka3. Dilkusha Branch ,Dhaka4. Mirpur Branch , Dhaka5. Dhanmondi Branch , Dhaka6. Uttara Branch , Dhaka

7. Moghbazar Branch ,Dhaka8. Bangshal Branch , Dhaka9. Agrabad Branch , Chittagong .10. Khatungonj Branch , Chittagong.12. Jubilee Road Br. Chittagong13. Gulshan Branch , Dhaka.14. Shyamoli Branch , Dhaka15. Banani Branch , Dhaka16. Bogra Branch , Bogra17. Comilla Branch , comilla18. Khulna Branch , Khulna

FIRST SECURITY ISLAMI BANK LTD.1. Dilkusha Branch ,Dhaka2. Mohakhali Branch, Dhaka3. Bangshal Branch , Dhaka

4. Dhanmondi Branch , Dhaka5. Gulshan Branch, Dhaka..6. Motijheel Branch, Dhaka.7. Ring Road Brach , Dhaka8. Banoshree Branch, Rampura, Dhaka.9. Khatungonj Branch , Chittagong10. Agrabad Branch , Chittagong .11. Jubilee Road Br. Chittagong12. Andar Killah Branch, Chittagong.13. Khulna Branch, Khulna14. Jessore Branch , Jessore.15. Topkhana Road Branch, Dhaka

One Bank Ltd1. Principal Branch, Dhaka.2. Kawran Bazar Branch, Dhaka.3. Motijheel Branch. Dhaka.

4. Gulshan Branch, Dhaka.5. Uttara Branch. Dhaka.6. Agrabad Branch, Chittagong.7. Khatunganj Branch, Chittagong.8.Nanupur Bazar Branch,Chittagong.9. Jubilee Road Branch, Chittagong.10. Sylhet Branch:, Sylhet.11. Bogra Branch, Bogra.

Dutch- Bangla Bank Ltd.22. Local Office, Dilkusha, Dhaka23. Motijheel F. Ex. Branch, Dhaka24. Nababpur Branch, Dhaka25. Banani Branch, Dhaka26. Kawran Bazar Branch, Dhaka27. Shantinagar Branch, Dhaka28. Dhanmondi Branch, Dhaka29. Narayangonj Branch, Narayangonj30. Agrabad Branch, Chittagong31. Mohakhali Branch, Dhaka32. Gulshan Branch, Dhaka33. Uttara Branch, Dhaka34. Khulna Branch, Khulna35. Sylhet Branch, Sylhet36. Bogara Branch, Bogra37. Barisal Branch, Barisal38. Moulavi Bazar Banch, Sylhet39. Rajshashi Branch, Rajshashi40. Khatungonj Branch, Chittagong41. Mirpur Circle -10 Branch, Dhaka42. Chhatak Branch, SunamganjEastern Bank Ltd.1. Principal Branch, Dhaka

2. Motijheel Branch, Dhaka3. Mirpur Br. Dhaka4. Bashundhara Branch, Dhaka5. Shyamoli Branch, Dhaka6. Narayanganj Br., Narayanganj7. Agrabad Branch , Chittagong8. Khatunganj Branch , Chittagong9. Bogra Branch, Bogra10. Khulna Branch, Khulna11. Rajshahi Branch, Rajshahi

United Commercial Bank Ltd.1. Principal Branch, Dhaka2. Kawran Bazar Branch, Dhaka3. Gulshan Branch, Dhaka

4. Faridpur Branch, Faridpur5. Foreign Exchange Branch, Dhaka6. Mohakhali Branch, Dhaka7. Dhanmondi Branch, Dhaka8. Banani Branch, Dhaka9. Gulshan Avenue Branch, Dhaka10. Khatungonj Branch, Chittagong11. Agrabad Branch, Chittagong12. Chowmuhani Branch, Feni13. Jublee Road Branch, Chittagong14. Sylhet Branch,Sylhet15. Shahjalal Upashahar, Branch, Sylhet16. Bogra Branch, Bogra

Investment Corporation ofBangladesh (ICB)

1. Head Office, Dhaka2. Local Office, Dhaka3. Chittagong Br. Chittagong4. Rajshahi Br. Rajshahi5. Sylhet Br. Sylhet6. Bogra Br. Bogra7. Khulna Br. Khulna8. Barisal Br. Barisal

National Bank Limited1. Agrabad branch, Chittagong.2. Anderkillah Branch, Chittagong3. Motijheel Branch, Dhaka4. Dhanmondi Branch, Dhaka5. Dilkusha Branch, Dhaka6. Elephant Road Branch, Dhaka7. Gulshan Branch, Dhaka

8. Imamganj Branch, Dhaka9. Jatrabari Branch, Dhaka10. Jublee Road Branch, Chittagong.11. Kawran Bazar, Branch, Dhaka12. Khatunganj Branch, Chittagong13. Narayanganj Branch, Dhaka14. Uttara Branch, Dhaka

IFIC Bank Limited1. Federation Branch, Dhaka2. Mohakhali Branch , Dhaka3. . Narayanganj Branch, Narayanganj.4. Dhanmondi Branch , Dhaka.5. Banani Branch,Dhaka.6. Shantinagar Branch.,Dhaka.7 Islampur Branch,Dhaka.

8. Naya Paltan Branch,Dhaka.9. Malibagh Branch, Dhaka.10. Stock Exchange Branch, Dhaka,.11. Pragoti sarani Branch, Dhaka.12. Agrabad Branch,Chittagong.13. Rajshahi Branch, Rajshahi14. Khulna Branch , Khulna.15. Jessore Branch , Jessore.16. Barisal Branch , Barisal17. Sylhet Branch, Laldihirpar, Sylhet.

54