Northern 3 VCT PLC Application Form - Clubfinance

4
DIVIDENDMANDATE
Dividends may be paid directly into Shareholders' bank and building society accounts. In order to facilitate this, please complete the
mandateinstructionformbelow.PleasenotethatifyouareanExistingShareholderthisinstructionappliestoallofyourshareholdingsin
theCompanyandcompletingtheformbelowwilldirecttheCompanytosendalldividendpaymentsdueonallyourshareholdingstothis
bankaccount.
Dividends paid directly to your account will be paid in cleared funds on the dividend payment dates. Your bank or building society
statementwillidentifydetailsofthedividendaswellasthedatesandamountspaid.
BycompletingthedetailsbelowIaminstructingtheCompanytoforward,untilfurthernotice,alldividendsthatmayfromtimetotime
becomedueonanySharesnowstanding,orwhichmayhereafterstand,inmynameintheregisterofmembersofNorthern3VCTPLCto
thebankorbuildingsocietyaccountlistedbelow.
NameofBankorBuildingSociety:
Branch:
5
6
BranchAddress:
AccountName:
SortCode:
Signed:
AccountNumber:
(pleasequotealldigitsandzeros)
TheCompanyandNVMdonotacceptresponsibilityifanydetailsprovidedbyyouareincorrect.
CREST
CompletethisboxonlyifyourequiresharestobeissuedelectronicallytoaCRESTaccount.
CRESTParticipantID:
CRESTMemberAccountID:
ParticipantName:
ParticipantAddress:
ParticipantPostcode:
ContactnameforCRESTqueries:
ContactTelephone:
Signed:
TOBECOMPLETEDBYAUTHORISEDINTERMEDIARIESONLY
Specialinstructions
PleaseprovidedetailsofyourbankaccountsothatcommissioncanbepaidtoyouviaBACS.
NameofBankorBuildingSociety:
Branch:
AccountName:
SortCode:
Emailaddressforcommission
statements:
AccountNumber:
(pleasequotealldigitsandzeros)
TheCompanyandNVMdonotacceptresponsibilityifanydetailsprovidedbyyouareincorrect.