Shareholder Details Update

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Bank Deposit Authority & Identity Confirmation

Name
Address
MM slash DD slash YYYY
MM slash DD slash YYYY
Gender
Please attach a pre-printed bank deposit slip OR fill in the details below and have a representative from your bank verify them.
Max. file size: 2 GB.
Max. file size: 2 GB.
I hereby authorise Mangatawa Papamoa Blocks Incorporation to deposit to the following bank account all distributions owing to me under their accounting control.