Application Form: Prospectus 3 of 2020

SUBSCRIBER DETAILS:

Name of applicant

ID / Registration number

Tax Reference Number

Total Rand value of offer shares applied for

Number of offer shares applied for

Price per offer share

Full names of authorized signatory

(If applicant is a legal entity)

Capacity of signatory

(If applicant is a legal entity)

Telephone

Email *

Deposit reference number *

*Please ensure that the deposit reference number entered above is quoted when making payment. The reference should read “DCL – “and your name.

Address *

Address

City

State/Province

Zip/Postal

Country

FICA DECLARATION:

Source of funds: *

In terms of section 42 of the Financial Intelligence Centre Act 38 of 2001 (“FICA”), an accountable institution must develop, document, maintain and implement a programme for anti-money laundering and counterterrorist financing risk management and compliance. For this reason all Investors have to declare FULL source of funds:

SUBSCRIBER BANKING DETAILS:

Account name

Account number

Bank

Branch

Account type

ACKNOWLEDGEMENTS AND UNDERTAKINGS BY APPLICANT:

Acknowledgements *

I / We undertake to pay the subscription amount to Destinata Capital Limited on date of or before delivering the application.

I / We warrant that the subscription price will be payable from a reputable source and shall not be in contravention of the Financial Intelligence Centre Act

I / We acknowledge and accept that the directors of Destinata reserve the right to accept or refuse any application for subscription, either in whole or in part, or to abate any or all application(s) (whether or not received timeously) in such manner as they may in their sole and absolute discretion determine, and further may accept or reject, in whole or in part, any application should the terms and conditions set out in this document not be fully complied with.

I warrant that the information set out below is true and correct.

I have been provided with the factual information, being the prospectus in terms of which the offer shares are offered for subscription, and understand that I have not been provided with advice as to the appropriateness of the investment to my particular needs or circumstances.

I have been duly and properly informed / advised of the full implications of my actions and, having considered same, hereby declare that I must obtain my own professional or investment advice, since the documents provided do not constitute investment advice, and that I should carefully consider whether the information / advice on its own is appropriate considering my objectives, financial situation and needs, to prevent the risk of concluding a transaction that is not appropriate to my needs, objectives and circumstances.

I agree to the terms and conditions

Terms & Conditions

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