UCB SA - BNP Paribas Fortis

A11250830/2.25/23 Oct 2009 139
Subscription form
Copy for the financial intermediary (financial agent)
UCB SA
60 Allée de la Recherche
B- 1070 Brussels
(VAT BE 0.403.053.608, RPM-RLP Brussels)
Public offer in Belgium and Luxembourg of 5.75% fixed rate bonds, due 27 November 2014, with a
nominal value of €1,000, as defined in the Prospectus (the “Bonds”)
ISIN CODE BE6000431112
SUBSCRIPTION FORM
(to be drawn up in duplicate, in accordance with the law)
I, the undersigned (name, first name) ............................................................................... ,
residing at …………………........, street .................................................... no. .................
have had the opportunity to become acquainted with the Prospectus of 23 October 2009 and declare that I
subscribe to:
................. Bonds with a nominal value of 1,000 euros each, at the subscription price of 101.875 % ,
or €1,018.75 for each Bond,
or €.................... in total.
For my subscription and as countervalue for the securities that are subscribed to, I request the bank,
.................. , to debit my account no. .............................. with the total subscription price.
I require that the Bond(s) be delivered in the form of an entry on the custody account no. ..........................
The paid amounts for the Bonds subscribed to and not allocated, will be refunded by Fortis Bank NV/SA,
ING Belgium NV/SA or KBC Bank NV, as the case may be, within seven (7) business days, without the
subscribers being entitled to demand interest on their payments.
Drawn up in duplicate at .................................................. on ......../.......... /...........
(subscriber’s signature)