Triodos Bank Organisation application for Depository Receipts in Triodos Bank NV.

Triodos Bank Organisation application for Depository Receipts in Triodos Bank NV.

Important notice In order to complete this application form you need to know what the current sterling price is for each Depository Receipt. Please contact us on 0800 328 2181 to confirm this price before starting your application. Depository Receipts are denominated in euro. If there is a movement in the exchange rate, or if the underlying share price in euro changes, we reserve the right to change this price. If this happens we will process your application for as many whole Depository Receipts as the amount you have paid will purchase and refund any difference to the account the payment came from within 14 calendar days. Please note we do not accept applications for organisations registered outside of the UK including those established, organised or incorporated in the United States or those with beneficial owner(s) who are US Persons. Guide to the Application Form The following instructions should be read in conjunction with the application form; Section 1 As you are applying on behalf of an organisation we will require some key information from you: The official name of your organisation. The registered and contact details for your organisation. The legal entity of your organisation. our personal details as the main contact person. Please ensure your full name, including title, permanent residential address and date of birth are completed in block capitals. If your organisation already holds accounts with Triodos Bank then the same contact person must be used for this application. If this person has changed then you will need to contact us separately to update this before completing this application form. our position within the organisation, as well as confirmation that you are authorised to apply on behalf of that organisation (we may need to contact you to verify this confirmation of authority). Section 2 In this section we require you to provide the details of your beneficial owners. They must be aged 18 or over to apply. Beneficial owners are individuals that either own or control more than 25% of your organisation. If you are a sole trader you do not need to complete this section. If you are a trust please provide the details of every trustee. Please also provide the details of every beneficiary that it has been determined will benefit from at least 25% of the trust property. If the trust operates for the benefit of a class of persons, please only provide the trustees details at this time. Please note we do not accept applications from organisations with beneficial owner(s) who are US Persons. Triodos Bank is required by law to identify beneficial owners. We may make an electronic search, using the information supplied on this form to verify identity and address of beneficial owners. In some instances we may ask them to send in further information or documents. Please ensure that your beneficial owners are aware of this. 1

Section 3 In box A, insert the number of Depository Receipts (in figures) you are applying for. In box B, insert the cost of Depository Receipts applied for. Please ensure you have contacted us to confirm this price. In box C, insert the transaction charge payable. In box D, insert the total amount payable. Section 4 This section of the application form is for you to tell us how you intend to pay for the Depository Receipts. If you are subscribing by electronic bank transfer, you must tell us which account the money will be sent from. The account must be an account in the organisations name. The funds must then be transferred electronically, from this account, to Triodos Bank DR subscription, account number 20222815 sort code 16-58-10. If we do not receive the deposit from this account within 14 calendar days of the price being given, your application will not be processed. Please contact your sending bank to carry out the instruction. If you are subscribing by cheque, you must include with the completed application form a cheque or banker s draft for the full amount payable. our cheque or banker s draft must be made payable to Triodos Bank NV, Depository Receipts for the amount payable and should be crossed A/C Payee. No receipt will be issued for this payment which must be solely for this application. our cheque or banker s draft must be drawn in sterling on the organisation s bank or building society account in the UK and must bear the relevant UK bank sort code in the top right hand corner. The purchase will only be made once we are sure your cheque account provider will pay us its value i.e. that the cheque has cleared. This could take up to seven Business Days from when we receive the cheque. If there is not sufficient money in your account to pay us the cheque s value i.e. the cheque is not cleared, then the purchase process will not start and the cheque will be returned to you. The right is reserved to reject any application in respect of which the applicant s cheque or banker s draft has not been cleared on first presentation. If applications are accompanied by a cheque or banker s draft drawn by someone other than the applicant, the cheque or banker s draft and application will be returned to the applicant. Section 5 ou must nominate an account for future dividend payments to be paid into. our nominated account must be a sterling account in the organisation s name with either another UK bank/building society or an existing UK Triodos Bank account that allows additional deposits. Section 7 All applicants must sign and date the declaration at the end of this application form. This is to confirm that you have fully read the Prospectus and agree to the terms under which Depository Receipts are issued. The Prospectus and full details can be found online at www.triodos.co.uk/prospectus If you have any queries on the application and payment procedure, please contact us on 0800 328 2181 or your financial adviser. 2

Please write in block capitals. Section 1 our details How did you hear about Triodos Bank? Application on behalf of an organisation Is your organisation established or organised in the United States? es No Is your organisation incorporated in the United States? es No If yes, please be aware that as per the Prospectus, you are not eligible to apply to purchase Depository Receipts so you should not proceed with this application. Official name of organisation Is your organisation an existing Triodos Bank Depository Receipt holder? es No If you are please give us your Depository Receipt Reference Number Does your organisation hold an existing UK Triodos Bank business account? es No If yes please detail an account number 3

Please complete all of the following sections: These are needed even if you are an existing customer. If we hold details about your organisation already and any of the details you provide during this application are different to these we may need to ask you for further confirmation or verification before we proceed with this application. If you do have changes to make to your existing records please contact us before applying. Organisation correspondence address Telephone Organisation email If you have a different registered office address from the above please complete this section Address 4

our status Please tick to confirm the entity of your organisation Company limited by guarantee Company limited by shares Co-operative Society Community Benefit Society Registered Society Limited Liability Partnership Community Interest Company Public Limited Company Charitable Incorporated Organisation Reg. no. Reg. no. Reg. no. Reg. no. Reg. no. Reg. no. Reg. no. Reg. no. Reg. no. Unincorporated society, club or similar body Partnership Sole Trader Trust* *If you are a trust please send us either the original or certified copy of your Trust Deed. If the trustees have changed from those named on the original trust deed, please also send the original or a certified copy of the deed of appointment or deed of retirement. The person undertaking the certification should be a professional person covered by money laundering regulations external to your organisation. For example, a person working in financial services, law or accountancy. The certifier must confirm they have seen the original, sign and date the copy, and also provide their name, professional position, work address and work telephone number. They may be contacted for verification. If you are a registered charity please provide us with your charity number Registered charity Reg no Tax Status We have to ask this question to comply with the International Tax Compliance Regulations. If you are uncertain of your organisation s tax status please consult a tax advisor. Is your organisation taxable in the UK? es No 5

Is your organisation taxable in any country other than the UK? es No If yes, where else is your organisation taxable? Please provide your Tax Identification Number () or equivalent if held e.g. Employer Identification Number, Unique Taxpayer Reference or Chamber of Commerce Number. Is your organisation a financial institution? (Financial institutions include holding companies of financial groups, custodial institutions, depository institutions, investment entities and specified insurance companies. If you are uncertain whether your organisation is a financial institution please consult a tax advisor or visit www.irs.gov) es No our details Contact person This will be the main contact person for correspondence and will have the authority to make changes to the details held about the organisation and authorise the sale of Depository Receipts. We will contact you using the organisation details provided. Personal details Title Mr / Mrs / Ms / Miss / Dr / Other First name(s) (for identification purposes, please use your full name and not a nickname) Surname Male Female 6

Permanent Residential Address Telephone (home)* Mobile* Email* (*if you are happy to be contacted by telephone and email in the future) How long have you lived at your current address? If you have lived at your current address for less than a year please give your previous address details below. Address Date of birth D D M M / / of birth Nationality our position within the organisation 7

Section 2 Beneficial owners If you have more than four beneficial owners please photocopy the section below and send in with the form. Beneficial owner 1 Are you a United States person? A United States person includes citizens and residents of the United States. Please see www.irs.gov for more details. es No If yes, please be aware that as per the Prospectus, Depository Receipts may not be applied for by US persons so you should not proceed with this application. Title Mr / Mrs / Ms / Miss / Dr / Other First name(s) (for identification purposes, please use your full name and not a nickname) Surname Date of birth D D M M / / Permanent Residential Address How long have you lived at your current address? 8

If you have lived at your current address for less than a year please give your previous address details below. Address Tax Residency Are you tax resident in the UK? es No Are you tax resident in any country other than the UK? es No If yes, where else are you tax resident? Please provide your Tax Identification Number () or equivalent for each country where you are tax resident. Beneficial owner 2 Are you a United States person? A United States person includes citizens and residents of the United States. Please see www.irs.gov for more details. es No If yes, please be aware that as per the Prospectus, Depository Receipts may not be applied for by US persons so you should not proceed with this application. Title Mr / Mrs / Ms / Miss / Dr / Other First name(s) (for identification purposes, please use your full name and not a nickname) Surname 9

Date of birth D D M M / / Permanent Residential Address How long have you lived at your current address? If you have lived at your current address for less than a year please give your previous address details below. Address Tax Residency Are you tax resident in the UK? es No Are you tax resident in any country other than the UK? es No If yes, where else are you tax resident? Please provide your Tax Identification Number () or equivalent for each country where you are tax resident. Beneficial owner 3 Are you a United States person? A United States person includes citizens and residents of the United States. Please see www.irs.gov for more details. es No If yes, please be aware that as per the Prospectus, Depository Receipts may not be applied for by US persons so you should not proceed with this application. 10

Title Mr / Mrs / Ms / Miss / Dr / Other First name(s) (for identification purposes, please use your full name and not a nickname) Surname Date of birth D D M M / / Permanent Residential Address How long have you lived at your current address? If you have lived at your current address for less than a year please give your previous address details below. Address Tax Residency Are you tax resident in the UK? es No Are you tax resident in any country other than the UK? es No If yes, where else are you tax resident? Please provide your Tax Identification Number () or equivalent for each country where you are tax resident. 11

Beneficial owner 4 Are you a United States person? A United States person includes citizens and residents of the United States. Please see www.irs.gov for more details. es No If yes, please be aware that as per the Prospectus, Depository Receipts may not be applied for by US persons so you should not proceed with this application. Title Mr / Mrs / Ms / Miss / Dr / Other First name(s) (for identification purposes, please use your full name and not a nickname) Surname Date of birth D D M M / / Permanent Residential Address How long have you lived at your current address? If you have lived at your current address for less than a year please give your previous address details below. Address 12

Tax Residency Are you tax resident in the UK? es No Are you tax resident in any country other than the UK? es No If yes, where else are you tax resident? Please provide your Tax Identification Number () or equivalent for each country where you are tax resident. Section 3 Depository Receipts and amount payable Before completing this section please ensure you have contacted us to obtain an up to date price for your purchase. Box A - number of Depository Receipts applied for (in figures) minimum 1 Box B - total cost of Depository Receipts applied for (A x quoted sterling price per DR) Box C - 0.5% transaction charge (B / 200) minimum charge 5 Box D - total amount payable (B + C) 13

Section 4 Subscription Please tell us how you would like to subscribe by ticking the boxes below: By electronic bank transfer This must be from a sterling account in your organisation s name with another UK bank/building society. Please give details below. Bank or Building Society name Account name Sort code Account number - - our transfer must be received by us within 14 calendar days of us receiving this application. Please contact your sending bank to carry out the instruction and make the payment to the following account: Account name: Triodos Bank DR subscription Sort Code: 16-58-10 Account number: 20222815 When transferring money please put your organisation s name as the payment reference. By cheque The cheque must be from an account in your organisation s name. It should be made payable to Triodos Bank NV, Depository Receipts. I enclose a cheque for By transfer from your existing Triodos UK account Please transfer from Triodos UK account number Please ensure that this request is signed in accordance with the account mandate held for the existing Triodos Bank account. 14

We will carry out this transfer on your behalf. If your existing Triodos Bank account has a notice period, it will be waived and no early access charge applied. Transfers that exceed 100,000.00 may experience delays. Signature First account holder Signature Second account holder Name Name Position Position Section 5 Transfer of dividends ou must nominate an account for dividend payments to be transferred to. our nominated account must be a sterling account in the organisation s name with either another UK bank/building society or an existing Triodos UK account that allows additional deposits. Bank or Building Society name Account name Sort code Account number - - or Triodos UK account number 15

Section 6 Communication We take a responsible and considered approach to how we communicate with you by email, telephone and post. We won t share your information with anyone else. Let us know your preferences. ou can change your preferences at any time. The impact of your money Being a Triodos Bank customer shows that you care about what your money does so let us show you the positive impact of your money. Our 'Colour of Money' publication, email newsletter and other inspirational pieces are a great way to stay connected with like-minded projects and organisations. es, I want to receive news about the positive impact of my money. By email By post No, I don t want to receive news about the positive impact of my money. Accounts and services We would like to keep you up-to-date with our accounts and services and will only send you information that we believe may be of interest to you. es, I want to receive information about accounts and services. By email By post No, I don t want to receive information about accounts and services. If you are an existing customer this will replace your current selections. 16

Section 7 The Declaration To: Triodos Bank NV I confirm that: I am authorised to apply on behalf of the organisation detailed in Section 1, and Any beneficial owners as listed in Section 2 are 18 years of age or over. The organisation offers to subscribe for the number of Depository Receipts in Triodos Bank NV set out in box A above. The organisation confirms that it has read the Prospectus and the Important Information about applying for Depository Receipts leaflet. The organisation agrees to accept the same, or any lesser number of Depository Receipts in respect of which this application may be accepted. The organisation understands that the cheque supporting this application will be presented for payment upon receipt and warrant that it will be paid on first presentation. Where subscription monies are to be paid electronically, no application for Depository Receipts will be accepted until payment of subscription monies has been made in full in accordance with the instructions provided in this form. The organisation confirms that they are registered in the UK. It hereby requests you to send correspondence to the address given in Section 1 (at the organisation s own risk). Depository Receipt confirmation in respect of such a number of Depository Receipts as may be allotted to the organisation will be sent to this address and any surplus application monies will be returned to the originating bank account. In completing this application form the organisation confirms that this is an execution only transaction. The organisation confirms that it has not received and is not expecting to receive advice about the investment merits of the transaction from Triodos Bank NV. Triodos Bank NV will not be responsible for ensuring that the transaction is suitable for the organisation. I confirm that each beneficial owner named on this form has consented to Triodos Bank NV verifying their identity and I acknowledge Triodos Bank NV's right to hold the processing of this application until each individual and the organisation has supplied to Triodos Bank NV any documentation that may be required. The organisation authorises Triodos Bank NV to make any enquiries deemed necessary to confirm the details on this form. 17

To the best of my knowledge, the particulars I have given on behalf of the organisation are correct. Signature Authorised person Signed Date D D M M / / our checklist Please check you have: Completed all relevant sections Signed and dated the Declaration Enclosed a cheque for your subscription (if applicable) Made a transfer from an account in the organisation s own name(s) (if applicable) Send the completed application form, together with the cheque or banker s draft (if you are subscribing by cheque) by post to our Freepost address (no stamp required). Our Freepost address is Royal Mail registered and simple to use, write it exactly as shown below on your envelope and your letter will get to us free of charge. Freepost TRIODOS BANK 18

Freephone: 0800 328 2181 contact@triodos.co.uk www.triodos.co.uk Calls to and from Triodos Bank NV may be recorded for training and monitoring purposes. Triodos Bank NV incorporated under the laws of the Netherlands with limited liability registered in England and Wales, registration number BR3012. Authorised by the Dutch Central Bank (DNB) and subject to limited regulation by the Financial Conduct Authority and Prudential Regulation Authority. Details about the extent of our regulation by the Financial Conduct Authority and Prudential Regulation Authority are available from us on request. Registered office: Triodos Bank, Deanery Road, Bristol BS1 5AS. VAT reg no 793493383. Triodos Bank NV 2015 Printed on 100% recycled paper TB/DR.AF.BB/DEC15