Rights Issue Please enable JavaScript in your browser to complete this form.Security *Select SecurityUnited Bank for Africa PlcChams Holding CompanyIndustrial & Medical Gases Nigeria Plc’s (IMG)CSCS A/c No *CHN No *Participation TypeParticipation TypeFull Acceptance/Request for additional ordinary sharesRenunciation or Partial AcceptanceLayoutNumber of Shares (Full Acceptance) *Amount payable (N50/Share) *Layout (Cham 1)Number of Shares (Full Acceptance) *Amount payable (N1.70/Share) *Layout IMGNumber of Shares (Full Acceptance) *Amount payable (N32.0/Share) *LayoutAdditional units appliedAdditional amount payable (N50/Share) Layout Cham 2Additional units appliedAdditional amount payable (N1.70/Share)Layout IMGAdditional units applied Additional amount payable (N32.0/Share) LayoutNumber of Shares AcceptedAdditional amount payable (N50/Share)Number of Shares RenouncedLayout Cham 3Number of Shares AcceptedAdditional amount payable (N1.70/Share)Number of Shares RenouncedLayout IMGNumber of Shares Accepted Additional amount payable (N32.0/Share) Number of Shares Renounced Customer TypeInidividualJointCorporateInvestor DetailsTitle *MrMrsMissMasterDrProfChief/SirSurnameFirst NameOther NamesLayoutEmail *Phone *Date of BirthResidential Address *LayoutState *Country *Joint Applicant DetailsTitle *MrMrsMissMasterDrProfChief/SirSurnameFirst NameOther NamesOccupation *Mobile Number *Email *BVN *Residential Address *Next Of Kin *Company NameType of BusinessR/C No.AddressEmail *Phone NumberContact Person *Bank Account InformationAccount Name *Account Number *Bank NameBVN *Form Upload (kindly upload files max 3MB in size)Form Upload * Click or drag a file to this area to upload. Evidence of Payment(1014048866 - Meristem Stockbrokers Limited- Zenith Bank) Click or drag a file to this area to upload. CommentSubmit
