1.

Name  .......................................................................................................................

2.

Telephone number....................................................................................................

3.

Fax number ...............................................................................................................

4.

Email address ............................................................................................................

5.

Details of mandated representative, including:

(a)

Designation ............................................................................................

(b)

Family name ...........................................................................................

(c)

First name ..............................................................................................

(d)

Telephone number .................................................................................

(d)

Fax number ............................................................................................

(e)

Email address .........................................................................................