Notification of bank account number for the purpose of dividend payout
I, the undersigned shareholder of NAFTA a.s., Votrubova 1, 821 09 Bratislava, ID: 36 286 192, registered
with the Commercial register of Bratislava I District Court, Section Sa, File No. 4837/B („NAFTA a.s.“)
Name and surname/ Trade name: .......................................................................................................
Residence/ Registered office: .................................................................................................................
Personal ID/ company ID: ........................................................................................................................
Represented by 1: .....................................................................................................................................
Commercial Register 1: .............................................................................................................................
Phone No.: ................................................................................................................................................
Health insurance company 2: ..................................................................................................................
am writing to notify you of the bank account number - in IBAN format – for the purpose of payout
of dividends for 2015
.................................................................................................................................................
If the shareholder agreed with processing of his/her personal data, the bank account number stated
in this notification will be binding for NAFTA a.s. for the purpose of dividend payout until receiving
a written notification of a change of the bank account number or a written withdrawal which shall
comply with the required details hereof.
I agree
I don’t agree
with processing my personal data including: phone number,
bank account number and name of the health insurance company for the purpose of dividend payout
and meeting the related obligations resulting from applicable legal regulations. Additionally, I confirm
that all data stated in my request for dividend payment were provided to NAFTA a.s. on a voluntary
basis, the data is true and up-to-date and I am aware of my rights as a person involved under Art 28 et
seq. of Act No. 122/2013 Coll. on Personal Data Protection and on changes and amendments to certain
acts.
..................................................................
attested3 signature of the shareholder
(for legal entities an officially attested signature4 of the person(s) authorised to act on behalf of the
legal entity)
The notification shall be delivered to the following address: NAFTA a.s., Votrubova 1, P.O.BOX 81505,
815 05 Bratislava
_____________________
1
Legal entities only; in this case please attach the Excerpt from the Commercial Register (for foreign legal entities: excerpt
from similar relevant register confirming existence of the legal entity and acting on behalf of the legal entity) not older than
3 months (the original copy or a certified photocopy)
2 Natural persons only
3 by Registry Office or a notary; in case of attestation of a signature outside Slovakia, the attestation shall meet the
requirements for attestation of signatures in that country (e.g. confirmed by an apostille, or. superlegalized)
4 The statutory body indicated in the attached excerpt from the Commercial Registry or other relevant registry