Application Form(Pages279 285)

7/27/2019 Application Form(Pages279 285)

1/13

kqvi evRvi wewbqvM Sz~wKcY|

Rb I eyS wewbqvM Kib|"Interested persons are entitled to a prospectus, if they so desire. Copies of the prospectus may be obtained from the issuer and the issue manager"

ORION PHARMA LIMITED

APPLICATION FORMAPPLICATION FOR SHARES BY INVESTORS OTHER THAN NON-RESIDENT BANGLADESHI(S)Warning: Please read the instructions at the back of this form. Incorrectly filled applications or applications failing to comply with any of the instructions therein may be rejected.

The Managing DirectorORION PHARMA LIMITEDOrion House,153-154 Tejgaon Industrial AreaDhaka-1208.

Bankers Sl. No.

Dear Sir,I/we apply for and request you to allot me/us . numbers of Shares and I/we agree cept the same or any smaller number that may be allotted to me/us upon termsof the Company's Prospectus approved by the Securities and Exchange Commission 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 Member(s) of the Company and deposit the said ordinary shares in my Beneficiary Owner ("BO") account; I/we furtherauthorize you to send a crossed (Account Payee only) cheque in respect of any Application money refundable to me/us by post/courier at my/our risk to the firstapplicant's

address stated below:

1. .No. of Ordinary Shares ............................of Tk. 60.00 each including apremium of Tk. 50.00 each.2. .Total subscription money of the amount of Tk. (in figures) .....................,Taka (in words) ..........................................................................................................onlydeposited vide cash/Cheque/Draft/Pay Order No. ............................Dated.................................on............................................... Bank..................................Branch.3. Beneficiary Owner (BO) Account Number

(If you do not mention your valid BO (Beneficiary Owner) Account Number, your application will be treated as invalid)4. I/we agree to fully abide by the instructions given herein.5. Particulars of Applicant :

a) Sole/First Applicant

Name :Father's/Husband's Name :Mother's Name:


2/13

Postal Address :Phone Number (if any):Occupation : Nationality :For Refund: Please write the correct and full name of bank and branch (Application will not be treated as valid if any one uses a non-scheduled bank. To avoid this complication,investors are requested not to use the name of any non-scheduled bank).For refund purpose: I/we want refund through Bank Account Hand Delivery/Courier(Please put tick mark in which refund will be made). The applicant shall providewiththe same Bank Account Number in the application form as it is in the BO accountof the applicant.Applicants Bank A/c no.Name of the Bank : Branch :

b) Second Applicant

Name:Father's/Husband's Name :Mother's Name:Postal Address :Occupation : Nationality:

6. .

I/we hereby declare that I/we have read the Prospectus of ORION PHARMA LIMITED and have willingly subscribed for .... No. of Ordinary Shares of 60.00each including a premium of Tk. 50.00 per share.7. .Specimen Signature(s) :(i) Name (in Block Letters) Signature:(ii) Name (in Block Letters) Signature:

In case of deposit into the applicant's bank account, the applicant will bear the applicable charge, if any, of the applicant's banker, and the issuer shall simultaneously issue a letterof intimation to the applicant containing, among others, the date and amount remitted with details of the bank through and to which bank such remittance has bee

n effected.............................................................................................................................................................................................................................................................................................

BANKERS' ACKNOWLEDGEMENT

Certified that this Bank has received Tk. (in figures)................. (in word ............................................................) only from Mr./Mrs./Ms................................................................................................................................ being the Application money for .............................

.... Ordinary Shares of ORION PHARMA LIMITED.

Authorized Signature

Banker's SL. No.Seal & Date

(Name & Designation)


3/13


4/13

INSTRUCTIONS

1. As per provision of Depository Act, 1999 and regulations made there under shares will only be issued in dematerialized condition. Please mention your Beneficiary Owner (BO) Account number in the Application form. If youdo not mention your valid BO account number, your application will be treated asinvalid.2. All information must be typed or written in full (in Block letters) inEnglish or in Bengali and must not be abbreviated.3. Application must be made on the Company's printed form/photocopy or ontyped copy/hand written form thereof.4. Application must not be for less than 100 Ordinary Shares and must be for a multiple of 100 Ordinary Shares. Any Application not meeting these criteriawill not 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. Remittance should be in the form of Cash/Cheque/Bank Draft/Pay Order payable toone of the Bankers to the favoring A/C ORION PHARMA LIMITED and crossed "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 and wher

e any amount is refundable in whole or in part the same will berefunded by Account Payee Cheque by post/courier service to the person named first on this Application Form in the manner prescribed in the Prospectus.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 must beaccompanied by Memorandum and Articles of Association and Certificate of Incorporation.9 An applicant cannot submit more than two applications, one in his/her own name and another jointly with another person. In case an applicant makes morethan two applications, all applications will be treated as invalid and

will not be considered for allotment purpose. In addition, 15% (fifteen) of theapplication money will be forfeited by the Commission and the balance amount will be refunded to the applicant.

10. No receipt will be issued for the payment made with Application, but the bankers will issue a provisional acknowledgement to the Issue for Applicationlodged 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 bankers to the Issue, refund amount of those applicants will be directly creditedin to the respective bank "Account Payee" cheque(s) with bank account number andname of bank branch as mentioned in the application payable at Dhaka or Chittag

ong, as the case may be.

12. Allotment shall 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 applicationmoney and/or forfeiture of the share (unit) before or after issuance of the sameby the issuer. The said forfeited application money or share (unit) will be dep


5/13

osited in account specified by the Securities and Exchange

Commission (SEC). This may be in addition to any other penalties as may be provided for by law.14. Applications, which do not meet the above requirements, or Applications, which are incomplete, shall not be considered for allotment purposes.15. The Banker's to the Issue Banks shall be obliged to receive the A/C Payee Cheque(s) on the closing day of the subscription.

16. No sale of securities shall be made, nor shall any money be taken from any person, in connection with such sale until twenty five days after the prospectus has been published.17. The applicants who have applied for more than two applications using same bank account, their application will not be considered for lottery and the Commission will forfeit 15% of their subscription money too.Banker to the Issue

Investment Corporation of Bangladesh (ICB) Zinzira Br., Dhaka. Rangpur Cantt. Br., Rangpur. Khulna Branch, Khulna. Moulvibazar Branch, Moulvibazar.NSC Tower, Purana Paltan, Dhaka. Tongi Branch, Gazipur. Momenshahi Cantt. Br. Mymensingh. Kushtia Branch, Kushtia Pahartali Branch, Chittagong.Chittagong Branch, Chittagong. Agrabad Branch, Chittagong. Savar Cantt. Br., Saver Cantonment, Dhaka. Boro Bazar Br., Kalibari, Khulna Chouhatta Branch, Sylhet.

Rajshahi Branch, Rajshahi. Jubilee Road Branch, Chittagong. Chittagong Cantt. Br., Chittagong. Jessore Branch, Jessore Laldighirpar Branch, Sylhet.Khulna Branch, Khulna. Khatungonj Branch, Chittagong. Comilla Cantt. Br., Comilla. Barisal Branch, Barisal Shahjalal Uposhahar Branch, Sylhet.Barisal Branch, Barisal. Andarkilla Br., Chittagong. S.S. Cantt. Br., Ghatail, Tangail. Sylhet Branch, Sylhet Kulaura Brnach, Moulvibazar.Sylhet Branch, Sylhet. Cox's Bazar Br., Chittagong. Bogra Cantt. Br., Bogra. Moulvi Bazar Branch, Moulvi Bazar. Pathantula Branch, Sylhet.Bogra Branch, Bogra. Chawkbazar Br., Chittagong. Kafrul Br., Dhaka. Uposhohor Branch, Sylhet. Agrabad Branch, Chittagong.Local Office, Kashfia Plaza, Nayapaltan, Pahartoli Br., Chittagong. Joydebpur Branch, Dhaka. Tultikar Branch, Sylhet. Khatunganj Brnach, Chittagong.Dhaka. Comilla Branch, Comilla. Chowmohoni Branch, Noakhali Jubilee Road Branch,

Chittagong.Bank Asia Ltd.Narsingdi Br., Narsingdi.Zinda Bazar Branch, Sylhet.Ashulia Br. Ashulia, Dhaka.Kadamtali Br., Kadamtali, Chittagong.Social Islami Bank LimitedPrincipal Branch, DhakaHalishahar Branch, Chittagong.Chowmuhani Branch, Noakhali.MCB Dilkusha Br., Dhaka.Corporate Br., Dhaka.Bandar Bazar Branch, Sylhet.

Amborkhana Br., Sylhet. Mutual Trust Bank Ltd.Agrabad Branch, ChittagongKhulna Branch, KhulnaCDA Avenue Branch, Chittagong.Cox's Bazar Branch, Cox's Bazar.Scotia Br. Karwan Bazar, Dhaka. Moulvi Bazar Br., Sylhet. Babu Bazar Branch, Dhaka. Gulshan Branch, Dhaka Chhagalnaiya Branch, Feni.Gulshan Br., Dhaka. Rajshahi Branch, Rajshahi. Banani Branch, Dhaka. Babu BazarBranch, Dhaka Feni Branch, Feni.MCB Banani Br., Dhaka. Bogra Branch, Bogra. Dhanmondi Branch, Dhaka. Begum Rokey


6/13

a Sarani Branch, Dhaka Chapainawabgan Branch, ChapainawabganjUttara Br., Dhaka. Rangpur Br., Rangpur. Dholaikhal Branch, Dhaka. Sonargaon Branch, Narayangonj Bashurhat Branch, Noakhali.Mitford Br., Dhaka. Sirajgonj Br., Sirajgonj. Dilkusha Branch, Dhaka. Foreign Exchange Branch, Dhaka Momin Road Branch, Chittagong.North South Rd Br., Dhaka. Khulna Branch, Khulna. Elephant Road Branch, Dhaka. Dhanmondi Branch, Dhaka Rangpur Branch, Rangpur.Dhanmondi Br., Dhaka. Jessore Br., Jessore. Fulbaria Branch, Dhaka. Uttara Branch, Dhaka Bogra Branch, Bogra.Bashundhara Br., Dhaka. Barisal Branch, Barisal. Gulshan Branch, Dhaka. Mirpur Branch, Dhaka Khulan Branch, Khulan.Sylhet Main Br., Sylhet. Mohammadpur Branch, Dhaka. Banani Branch, Dhaka BarisalBranch, Barisal.Sylhet Uposhahar Br., Sylhet.Agrabad Branch, Chittagong.Khatunganj Br., Chittagong.MCB Sk. Mujib Road Br, Agrabad, Chittagong.Bahadderhat Br., Chittagong.Moghbazar Br., Dhaka.CDA Avenue Br., Chittagong.Station Road Br., ChittagongRajshahi Br., Rajshahi.Khulna Br., Khulna.Mohakhali Br., Dhaka.

Mirpur Br., Dhaka.Bogra Br., Bogra.Jessore Br., Jessore.Anderkilla Br., Chittagong.Shantinagar Br., Dhaka.Progati Sarani Br., Dhaka.Kamal Bazar Br., Chittagong.Ishwardi Branch, Pabna.BRAC Bank Ltd.Asad gate Br., Dhaka.Banani Br., Dhaka.Bashundhara Br., Dhaka.Donia Br., Dhaka.

Eskaton Br., Dhaka.Graphics Building Br., Dhaka.Gulshan Br., Dhaka.Manda Br., Dhaka.Mirpur Br., Dhaka.Narayanganj Br., Narayanganj.Nawabpur Br., Dhaka.Rampura Br., Dhaka.Shyamoli Br., Dhaka.Uttara Br., Dhaka.Agrabad Br., Chittagong.CDA Avenue Br., Chittagong.Halishahar Br., Chittagong.

Kazirdeuri Br., Chittagong.Momin Road Br., Chittagong.Bogra Br., Bogra.Rajshahi Br., Rajshahi.Jessore Br., Jessore.Khulna Br., Khulna.Barisal Br., Barisal.Zindabazar Br., Sylhet.Patia Branch, Chittagong.The City Bank Ltd.


7/13

B.B. Avenue Branch, Dhaka.Dhaka Chamber Branch, Dhaka.Dhanmondi Branch, Dhaka.Shaymoli Branch, Dhaka.ONE Bank LimitedPrincipal Branch, Dhaka.Motijheel Branch, Dhaka.Karwan Bazar Branch, Dhaka.Gulshan Branch, Dhaka.Mirpur Branch, Dhaka.Uttara Branch, Dhaka.Dhanmondi Branch, Dhaka.Banani Branch, Dhaka.Kakrail Branch, Dhaka.Progoti Sarani Branch, Dhaka.Elephant Road Br. Dhaka.Jatrabari Br. Dhaka.Nawabgonj Br. Dhaka.Bangshal Br. Dhaka.Ganakbari (EPZ) Br. Savar, Dhaka.Imamganj Br. Imamganj, Dhaka.Narayanganj Br. Narayanganj.Jaypara Br. Dohar, Dhaka.Agrabad Br. Chittagong.

Khatunganj Br. Khatunganj, Chittagong.CDA Avenue Br. Kotwali, Chittagong.Nanupur Bazar Br. Fatickchari, Chittagong.Cox's Bazar Br, Chittagong.Jubilee Road Br, Chittagong.Chowmuhani Branch, Noakhali.Chandragonj Branch, Lakshmipur.Feni Branch, Feni.Raipur Branch, Lakshmipur.Dagon Bhuiyan Branch, Feni.Sylhet Branch, Sylhet.Sherpur Branch, Moulvi Bazar.Islampur Branch, Sylhet.

Jessore Branch, Jessore.Bogra Branch, Bogra.Serajgonj Branch, Serajgonj Sadar.Laksham Branch, Laksham.Ramgonj Branch, Lakshmipur.Maijdee Court Branch, Noakhali.Banasree Branch, Dhaka.Rajshahi Branch, Rajshahi.Shahjadpur Br. Sirajgonj.Jagannathpur Branch, Nadda, Dhaka.Tongi Branch, Gazipur.Comilla Branch, Comilla.Basabo Branch, Sabujbag, Dhaka.

Satkhira Br. Satkhira.Madhabdi Br. Narsingdi.Rangamati Br. Rangamati.Sitakunda Br. Sitakunda, Cgittagong.Moghbazar Br. Ramna, Dhaka.MTB Corporate Center Branch, Dhaka.Pllabi Branch, Dhaka.Panthapath Branch, Dhaka.Principal Branch, Dhaka.Progati Sarani Branch, Dhaka.


8/13

Savar Branch, Dhaka.Shanir Akhra Branch, Dhaka.Tongi Branch, Dhaka.Uttara Model Town Branch, Dhaka.Narayanganj Branch. NarayanganjSonargaon Branch. NarayanganjAgrabad Branch, Chittagong.Alankar Mour Branch, Chittagong.CDA Avenue Branch, Chittagong.Jubilee Road Branch, Chittagong.Khatungonj Branch, Chittagong.Feni Branch, Feni.Rajshahi Branch, Rajshahi.Rangpur Branch, Rangpur.Bogra Branch, Bogra.Pabna Branch, Pabna.Kushtia Branch, Kushtia Sylhet Branch, Sylhet.Moulvi Bazar Branch,Sylhet.Gournadi Branch, Barisal.Jessore Branch, Jessore.Hobigonj Branch, Hobigonj.IFIC Bank LimitedFederation Branch, Dhaka.Dhanmondi Branch, Dhaka.

Moakhali Branch, Dhaka.Banani Branch, Dhaka.Shantinagar Branch, Dhaka.Elephant Road Branch, Dhaka.Islampur Branch, Dhaka.Kawran Bazar Branch, DhakaNaya Paltan Branch, Dhaka.Uttara Branch, Dhaka.Malibagh Branch, Dhaka.Pallabi Branch, Dhaka.Lalmatia Branch, Dhaka.Narsingdi Branch, NarsingdiNorth Brook Hall Road Br., Dhaka.

Narayangonj Branch, Narayangonj.Faridpur Branch, Faridpur.Mymensingh Branch, Mymensingh.Stock Exchange Br., Motijheel, Dhaka.Pragati Sarani Br., Uttar Badda, Dhaka.Agrabad Branch, Chittagong.CDA Avenue Branch, Chittagong.Madam Bibir Hat Br., Shitakundo, Chittagong.Sk. Mujib Rd. Br., ChittagongIslampur Branch, DhakaRampura Branch, DhakaNew Eskaton Branch, DhakaRasulpur Br., Dhaka

Rajshahi Branch, Rajshahi.Bogra Br., Bogra.Halishahar Br., Chittagong.Comilla Branch, Comilla.Shahjalal Islami Bank LimitedDhaka Main Br., Dilkusha, Dhaka.Mitford Br., Mitford Road, Dhaka.Dhanmondi Br., Dhaka.Gulshan South Avenue Br., Gulshan, Dhaka.Agrabad Branch, Chittagong.


9/13

Sylhet Branch, Sylhet .Khatungonj Branch, Chittagong.Gulshan Br., Gulshan, Dhaka.Foreign Ex. Br., Motijheel, Dhaka.Ashkona Branch, Ashkona, Dhaka.Kawran Bazar Br., Dhaka.Banani Br., Banani, Dhaka.Satmasjid Road Br., Dhanmondi, Dhaka.Eskaton Branch, Ramna, Dhaka.Jubilee Road Br, Chittagong.Motijheel Br., Motijheel, Dhaka.Mirpur Br., Mirpur-10, Dhaka.Uttara Br., Uttara, Dhaka.Savar Br., Savar, Dhaka.Bangshal Br., Bangshal, Dhaka.Bijoynagar Br., Kakrail, Dhaka.Dargah Gate Branch, Sylhet.Southeast Bank Ltd.Principal Branch, Dhaka.Corporate Branch, Dhaka.Imamganj Branch, Dhaka.Dhanmondi Branch, Dhaka.Uttara Branch, Dhaka.New Elephant Road Br., Dhaka.

Gulshan Branch, Dhaka.Kakrail Branch, Dhaka. Banani Branch, Dhaka.Bangshal Branch, Dhaka.New Eskaton Branch, Dhaka.Agargaon Branch, Dhaka.Sat Masjid Road Branch, Dhaka.Shaymoli Branch, Dhaka.Aganagar Branch, Dhaka.Pragati Sarani Br., Dhaka.Madhabdi Branch (Rural), Narshingdi.Ashulia Branch (Rural), Dhaka.Narayangonj Branch, Narayangonj.Rajshahi Brnach, Rajshahi.

Naogaon Branch, Naogaon.Madambibir Hat Branch, Chittagong.Comilla Branch, Comilla.National Bank LimitedAgrabad Branch, ChittagongAnderkillah Branch, Chittagong.Bangshal Road Branch, Dhaka.Banani Branch, Dhaka.Babubazar Branch, Dhaka.Bogra Br., Bogra.Barisla Branch, Barisal.Elephant Road Branch, Dhaka.Foreign Exchange Br, Dhaka.

Gulshan Branch, Dhaka.Imamgonj Branch, Dhaka.Islampur Branch, Dhaka.Jatrabari Branch, Dhaka.Kawranbazar Branch, Dhaka.Khulna Branch, Khulna.Sylhet Branch, SylhetFeni Branch, Reni.S.K. Mojib Road Branch, Chittagong.Z.H. Sikder M.C. Branch, Dhaka.


10/13

Malibag Branch, Dhaka.Khatungonj Branch, Chittagong.Lake Circus Branch, Dhaka.Tongi Brnach, Gazipur.Rifles Square Branch, Dhaka.Pagla Brazar Branch, Narayangonj.CDA Avenue Branch, Chittagong.Muradpur Branch, Chittagong.Zidnabazar Branch, Sylhet.Mirpur Branch, Dhaka.Mohakhali Branch, Dhaka.Mohammadpur Branch, Dhaka.Motijheel Branch, Dhaka.Dhanmondi Branch, Dhaka.Dilkusha Branch, Dhaka.New Eskaton Branch, Dhaka.North Brooke Hall Branch, Dhaka.Pragati Sarani Branch, Dhaka.Rokeya Sarani Branch, Dhaka.Savar Bazar Branch, Savar.Uttara Branch, Dhaka.Chawkbazar Branch, Chittagong.Chomuhani Branch, Chittagong.Pahartoli Brnach, Chittagong.

Halishahar Branch, ChittagongJubilee Road Brnach, Chaittagong.Tangail Branch, Tangail.Imamagonj Branch, Dhaka.Johnson Road Branch, Dhaka.Kawranbazar Branch, Dhaka.New Market Branch, Dhaka.VIP Road Branch, Dhaka.Islampur Branch, Dhaka.Nawabgonj Branch, DhakaNawabpur Branch, Dhaka.Pragati Sarani Br., Dhaka.Tanbazar Branch, Narayangonj.

Trust Bank Limited.Radisson Water Garden Hotel Br., Dhaka.Narsingdi Branch, Narsingdi.Khulna Br., KDA Avenue, Khulan.Jalalabad Cantt. Br., Sylhet.Ashugonj Br., Ashugonj, Brahmanbaria.Tongi Branch, Dhaka.Dilkusha Corporate Br., Dhaka.Principle Branch, Dhaka.Cox's Bazar Branch, Cox's BazarComilla Branch, ComillaFeni Branch, Feni.Choumuhani Br., Noakhali

B. baria Branch, Brahmanbaria.Rajshahi Branch, RajshahiRangpur Branch, RangpurBogra Branch, BograPabna Branch, PabnaDinajpur Branch, DinajpurJoypara Branch (Rural), Dhaka.Savar Branch, Dhaka.Mouchak Branch, Dhaka.Konabari Branch (Rural), Gazipur.


11/13

Tongi Branch, Gazipur.Bashundhara Branch, Dhaka.Mohammadpur Branch, Dhaka.Rokeya Sarani Branch, Dhaka.Fatikchari Brnach, Chittagong.Bandar Bazar Branch, Sylhet.Comilla Branch, Comilla.Rangpur Branch, Rangpur.Rajshahi Branch, Rajshahi.Narayangonj Branch, Narayangonj.Netaigonj Branch, Narayangonj.Narsingdi Branch, Narsingdi.Faridpur Branch, Faridpur.Mouvibazar Branch, Mouvibazar.Mymensingh Branch, Mymensingh.


12/13

kqvi evRvi wewbqvM SzwKc~Y|Rb I eyS wewbqvM Kib|"Interested persons are entitled to a prospectus, if they so desire. Copies of the prospectus may be obtained from the issuer and the issue manager"

ORION PHARMA LIMITED

APPLICATION FORMAPPLICATION FOR SHARES BY AFFECTED SMALL INVESTORS (wZM z

`wewbqvMKvix)

Warning: Please read the instructions at the back of this form. Incorrectly filled applications or applications failing to comply with any of the instructions therein may be rejected.

The Managing DirectorORION PHARMA LIMITEDOrion House,153-154 Tejgaon Industrial Area

Bankers Sl. No.Dhaka-1208.

Dear Sir,I/we apply for and request you to allot me/us . numbers of Shares and I/we agree cept the same or any smaller number that may be allotted to me/us upon termsof the Company's Prospectus approved by the Securities and Exchange Commission 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 Member(s) of the Company and deposit the said ordinary shares in my Beneficiary Owner ("BO") account; I/we furtherauthorize you to send a crossed (Account Payee only) cheque in respect of any Ap

plication money refundable to me/us by post/courier at my/our risk to the firstapplicant'saddress stated below:

1. .No. of Ordinary Shares ............................of Tk. 60.00 each including apremium of Tk. 50.00 each.2. .Total subscription money of the amount of Tk. (in figures) .....................,Taka (in words) ..........................................................................................................onlydeposited vide cash/Cheque/Draft/Pay Order No. ............................Dated.................................on.............................................

.. Bank..................................Branch.3. Beneficiary Owner (BO) Account Number(If you do not mention your valid BO (Beneficiary Owner) Account Number

, your application will be treated as invalid)4. I/we agree to fully abide by the instructions given herein.5. Particulars of Applicant :

a) Sole/First Applicant

Name :


13/13

Father's/Husband's Name :Mother's Name:Postal Address :Phone Number (if any):Occupation : Nationality :For Refund: Please write the correct and full name of bank and branch (Application will not be treated as valid if any one uses a non-scheduled bank. To avoid this complication,investors are requested not to use the name of any non-scheduled bank).For refund purpose: I/we want refund through Bank Account Hand Delivery/Courier(Please put tick mark in which refund will be made). The applicant shall providewiththe same Bank Account Number in the application form as it is in the BO accountof the applicant.Applicants Bank A/c no.Name of the Bank : Branch :

b) Second Applicant

Name:Father's/Husband's Name :Mother's Name:Postal Address :Occupation : Nationality:

6. I/we hereby declare that I/we have read the Prospectus of ORION PHARMALIMITED and have willingly subscribed for .... No. of Ordinary Shares of 60.00each including a premium of Tk. 50.00 per share.7. Specimen Signature(s) :

(i) Name (in Block Letters) Signature:(ii) Name (in Block Letters) Signature:

In case of deposit into the applicant's bank account, the applicant will bear the applicable charge, if any, of the applicant's banker, and the issuer shall simultaneously issue a letterof intimation to the applicant containing, among others, the date and amount rem

itted with details of the bank through and to which bank such remittance has b

Application Form(Pages279 285)

Documents

Transcript of Application Form(Pages279 285)