Form Filling Instructions
1. The person is to fill this form where the person is subject to one or more of the events mentioned in article (33) of the Listing Rules.
2. The person has full responsibility for the correctness of the information contained in this form.
3. The signed form is to be sent to the below addresses by no later than the end of the third trading day following the execution of the transaction or the occurrence of the event in which the obligation to notify arose:
Saudi Stock Exchange (Tadawul) – Listing Authorization & Oversight Department/ Regulatory Oversight &
Authorization Division – Fax: 011 2189226, Email: [email protected] then sent by registered mail to the postal address: Riyadh 12211 - 3388 unit 15 - Saudi Stock Exchange (Tadawul).
1. Name
Identity Number / Commercial Registration
Notification Type Owner of, or is interested in 5% or
more Change of Interest
2.
Name of the listed company that has been acquired in3. Direct Ownership
Number and class of shares /convertible debt instruments owned
Percenta ge
4. Vested Interest
a
. Are there shares /convertible debt instruments
owned or controlled by the person's relatives? Yes No
b .
Are there shares /convertible debt instruments owned or controlled by a company controlled by the person?
Yes No
c .
Are there shares /convertible debt instruments owned or controlled by other persons with which that the person has agreed to act in concert to acquire interest in or exercise voting rights in the shares/convertible debt instruments of the issuer?
Yes No
If answered "Yes" to any of the above questions, please fill out the following table:
Percenta ge Number of
shares or convertible
debt Relationsh
ip (Interest) Identity Number/
Commercial Registration Name
Classific ation: In ternal Classific ation: In ternal
Disclosure Form
( (2
Ownership
instruments
1 2 3
Classific ation: In ternal Classific ation: In ternal
4 5 6
Percentag e Number and class of shares
/convertible debt instruments the person has an interest in
The total percentage of shares /convertible debt instruments the person owns, or has an interest in.
Total (3+4)
5.
If there is a change of interest, please fill out the following table:
6. Change of Interest
Number and class of shares /convertible debt instruments owned before change
Percentage before change
Number and class of shares /
convertible debt instruments owned after change
Percentage after change
Change Reason Percentag
e Number of
shares or convertible instrumentsdebt Relationship
(Interest) Identity
Number/
Commercial Registration
7
Name.
1 2 3 4 5 6Percentag e Number and class of shares
/convertible debt instruments that has change of interest
8.
Details of OwnershipProcess Bought form the
Market Other (………...)
9.
Financing Source Personal Other (………...)10
.
Contact Information
Name Fax
Reporting
date Address
Telephone
#
Mobile
#