Application form for the admission and registration of an Authorized representative on the Luxembourg Stock Exchange

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1 Application form for the admission and registration of an Authorized representative on the Luxembourg Stock Exchange This application will not be taken into consideration until this form and all necessary documents have been returned to the Membership Department. The Membership Department may request additional information.

2 1. Details of the member (to be completed by the member firm) Corporate name of the member firm: Member address: Country: Member capacity: Broker Dealer: requests the admission of the following person: Name and first name: Position with the member firm: in the function of Authorized representative. 2

3 2. Details of the prospective Authorized representative This section to be completed by the prospective Authorized representative) Name: First name(s): Office address: Telephone (office): Fax: Mobile phone: (office) Nationality: Date of birth: Place of birth: I. Are you authorized to represent the Member by virtue of the law, articles of association, rules or otherwise? Yes No If yes, please explain and enclose a copy of the authorization: II. Are you responsible or jointly responsible for the daily management of the Member? Yes No If yes, explain: 3

4 3. Statement by the prospective Authorized representative 1. By signing this form, the prospective Authorized representative agrees to comply immediately with requests from the Membership department of the Luxembourg Stock Exchange for any information, which this department deems necessary for a thorough evaluation of this application. 2. The prospective Authorized representative agrees that in connection with this application, the Membership department of the Luxembourg Stock Exchange may request information on the prospective Authorized representative from authorities and/or persons (previous employers etc.). 3. The prospective Authorized representative also agrees and hereby grants permission for any information on him/her present in the files kept by the competent authority to be provided to the Luxembourg Stock Exchange in connection with his/her application for Authorized representative. 4. The prospective Authorized representative also accepts the obligation that the Luxembourg Stock Exchange shall be able to reach him/her at all times during trading hours. The undersigned declares that this form and the appendices have been completed truthfully and in full. Signature of the Member (person authorized to represent the company) Name / First name: Position: Signature: Date and place: Signature of the prospective Authorized representative 4

5 Sont à joindre les pièces suivantes: Please attach the following documents: A copy of a legally valid proof of identity (identity card or passport) A recent extract from the judicial record or a certificate of good conduct A recent professionnel curriculum vitae of the Authorized representative If necessary, a copy of the authorization to represent the Member by virtue of the law, articles of association, rules or otherwise (as detailed in point 2. I.) All changes to the above information must be reported immediately in writing to the Membership Department of the Luxembourg Stock Exchange using the appropriate form. Please send this form to SOCIETE DE LA BOURSE DE LUXEMBOURG S.A. Département Membres B.P. 165 L-2011 LUXEMBOURG 5