PURCHASE/DEPOSIT/ISSUANCE REQUEST. Taiwan Liposome Company, Ltd. American Depositary Shares (the "Issue")

Transcription

1 PURCHASE/DEPOSIT/ISSUANCE REQUEST TO: JPMORGAN CHASE BANK, NA. TAIPEI BRANCH Fax No.: Back-up Fax No.: RE: FROM: Taiwan Liposome Company, Ltd. American Depositary Shares (the "Issue") JPMORGAN CHASE BANK, DELAWARE OPERATIONS We forward the following received by us on, 201_. Sequential No. 12 JPMorgan Chase Bank Delaware Authorized Signature

2 ADR ISSUANCE REQUEST FOR PURCHASE OF SHARES / DEPOSIT / ISSUANCE OF AMERICAN DEPOSITARY SHARES OR DEPOSIT OF SHARES / ISSUANCE OF AMERICAN DEPOSITARY SHARES ("REQUEST") TO: FROM: JPMORGAN CHASE BANK, DELAWARE OPERATIONS ("Requestor") Acting on behalf of: DATE: I. THE REQUEST 1. Mandatory Information a. Name of issuer Taiwan Liposome Company, Ltd. b. Depositary JPMorgan Chase Bank, N.A. c. Requestor contact Requestor name Contact person Fax Telephone

3 d. Requestor's status (only required for deposit request) e. ADR issuance instructions DTC participant no. and account no. (1) Insider (as defined below) 1 of Issuer 2 Non-Insider of Issuer (2) R.O.C. Person or Entity Foreign Investor Approved by R.O.C. authorities pursuant to the Regulations Governing Securities Investment by Overseas Chinese and Foreign Nationals or Foreign Investor Approved by R.O.C. authorities pursuant to the Statute for Investment by Foreign Nationals or Statute for Investment by Overseas Chinese (a "FIA Investor") 3. Account name Contact person 1 A person or entity is deemed to be an "Insider" of Issuer if the person or entity is a director, supervisor, manager or shareholder holding more than 10% of the share capital of Issuer. Any Insider's spouses, minor children or nominees are also deemed as "Insiders". 2 If Depositor is an Insider, a copy of the approval for deposit from the R.O.C. Securities and Futures Commission must be delivered to the Depositary and JPMorgan Chase Bank, N.A. Taipei Branch (the Local Custodian ) together with submission of the Deposit Request. 3 If Depositor is a FIA Investor, the approvals for deposit from the Investment Commission, the Ministry of Economic Affairs or other R.O.C. authorities and the R.O.C. Securities and Futures Commission must be delivered to the Depositary and the Local Custodian together with submission of the Deposit Request.

4 2. Information for Purchase / Issue request (the total number of Taiwan Shares requested to be purchased, when combined with any Taiwan Shares intended to be deposited under 3 below must equal or exceed 50,000 Taiwan Shares. If less than the requested number of Taiwan Shares are purchased, all such whole lots purchased will be deposited to create ADSs, even if the total number to be deposited is fewer than 50,000 Taiwan Shares) f. Number of Taiwan Shares Requested to be purchased (a multiple of whole lot shares, i.e. 1,000 shares) Taiwan Shares (each ADS represents two Taiwan Shares) g. Selected Taiwan Broker (request will be rejected if left blank) h. Pre-Advice Remittee bank Amount remitted Value date i. Repatriation remittance instruction Remittee bank SWIFT code Correspondence bank Correspondence bank SWIFT code Requester's A/C No. Beneficiary j. DR issuance instructions DTC participant no. and account no. Account name Contact person

5 3. Information for Deposit / Issue request: (the total number of Taiwan Shares intended to be deposited, when combined with any Taiwan Shares requested to be purchased under 2 above must equal or exceed 50,000 Taiwan Shares. As long as the total number of Taiwan Shares requested to be purchased under 2 above along with those requested to be deposited under this section 3 totals or exceeds 50,000 Taiwan Shares, all such Taiwan Shares so purchased under 2 above and all Taiwan Shares sought to be deposited under this section 3, so long as a whole lot, will be deposited to create ADSs.) f. Number of Taiwan Shares Deposited (a multiple of whole lot shares, i.e. 1,000 shares) g. Taiwan Broker/Custodian Taiwan Shares (each ADS represents two Taiwan Shares) h. TDCC account no. II. PROCEDURES This request shall be faxed by the Requestor to the Depositary at: Notes: JPMORGAN CHASE BANK, DELAWARE OPERATIONS Fax No.: or (back-up line) (i) (ii) PRIOR TO FAXING REQUEST, REQUESTOR MUST HAVE IN PLACE WITH THE DEPOSITARY A SIGNED PROCEDURES LETTER. THE DEPOSITARY SHALL HAVE NO OBLIGATION TO ACT UPON THIS REQUEST UNLESS ALL ITEMS HEREIN ARE COMPLETE AND UNAMBIGUOUS AND THIS REQUEST IS SIGNED BY AN AUTHORIZED PERSON. III. INDEMNITY The Requestor agrees to indemnify the Depositary, the Local Custodian, and each of their respective officers, employees, directors, affiliates and agents, and to hold each harmless, against each and all costs, losses, liabilities, penalties, fines, charges and expense (including fees and expenses of counsel), which may arise out of acts performed or omitted, in connection herewith or in reliance hereupon by either the Depositary, the Local Custodian or their respective agents, directors, employees, agents and/or affiliates, or which may arise by reason of the inaccuracy of any information contained herein.

6 IV. GOVERNING LAW AND JURISDICTION This Request shall be governed by and construed in accordance with the laws of the State of New York, the United States of America. This Request is made as of the date first above written. (insert name of Requestor) By: Name: Title: