THIS DOCUMENT IS IMPORTANT AND REQUIRES YOUR IMMEDIATE ATTENTION. If you
are in any doubt about what action to take, you should immediately consult
your stockbroker, bank manager, lawyer, accountant or other professional or
investment advisor.
If you have sold all your shares in Laboratorio Chile S.A. (the
"Company"), please send this Form together with the accompanying documents as
soon as possible to the purchaser or to the stockbroker, bank or other agent
through whom the sale was effected for transmission to the purchaser.
This document should be read in conjunction with the U.S. Offer to
Purchase dated July 31, 2001 (the "U.S. Offer To Purchase"). The definitions
used in the U.S. Offer to Purchase apply in this Form of Acceptance (the
"Form"). All terms and conditions contained in the U.S. Offer to Purchase
applicable to the U.S. Offer (as defined in the U.S. Offer to Purchase) for
Shares are deemed to be incorporated in and form part of this Form.
FORM OF ACCEPTANCE
To Tender Shares of Common Stock
of
LABORATORIO CHILE S.A.
Pursuant to the U.S.
Offer To Purchase
dated July 31, 2001
by
IVAX HOLDINGS C.I.
a wholly-owned subsidiary of
IVAX CORPORATION
THE U.S. OFFER AND WITHDRAWAL RIGHTS WILL EXPIRE AT 5:30 P.M., NEW YORK CITY
TIME, ON WEDNESDAY, AUGUST 29, 2001, UNLESS THE U.S. OFFER IS EXTENDED.
The Receiving Agent for the U.S. Offer is:
THE BANK OF NEW YORK
By Mail: Facsimile Transmission: By Hand or Overnight
Courier:
(For Eligible Institutions Only)
The Bank of New York (212) 815-6339
101 Barclay Street, 7E The Bank of New York
New York, NY 10286 Fax Confirmation Telephone: 101 Barclay Street
Attention: (212) 815-3687 (collect) Corporate Trust Services
Window
New York, NY 10286
Attention:
DELIVERY OF THIS FORM OF ACCEPTANCE TO AN ADDRESS OTHER THAN AS SET
FORTH ABOVE WILL NOT CONSTITUTE A VALID DELIVERY. DELIVERY OF THIS FORM OF
ACCEPTANCE TO A BOOK-ENTRY TRANSFER FACILITY WILL NOT CONSTITUTE VALID
DELIVERY TO THE RECEIVING AGENT.
The instructions accompanying this Form of Acceptance should be read
carefully before this Form of Acceptance is completed.
THIS FORM OF ACCEPTANCE IS TO BE USED ONLY FOR TENDERING SHARES (AS
DEFINED BELOW). DO NOT USE THIS FORM OF ACCEPTANCE FOR TENDERING ADSs OR FOR
ANY OTHER PURPOSE.
Action to be taken to accept the U.S. Offer
Please read the detailed instructions on how to complete this Form. This
Form should only be used to accept the U.S. Offer if you are a registered U.S.
holder of Shares of the Company (the "Shares"). Shares beneficially owned or
held of record by persons who are not U.S. holders cannot be tendered pursuant
to the U.S. Offer and can only be tendered pursuant to the concurrent Chilean
Offer (as defined in the U.S. Offer to Purchase). If you are a holder of
American Depositary Shares ("ADSs"), you will receive and should complete an
ADS Letter of Transmittal and related documents in accordance with the
instructions set out therein. If you wish to accept the U.S. Offer, send the
completed and signed Form, together with the documents identified below to The
Bank of New York (the "Receiving Agent"), at the address set forth on the back
cover of the U.S. Offer to Purchase as soon as possible and in any event so as
to arrive not later than 5:30 p.m., New York City time, on Wednesday, August
29, 2001, unless the U.S. Offer is extended.
If your Titulo(s) and other documentation are not readily available or
are lost, this Form should nevertheless be completed, signed and returned as
stated above so as to arrive not later than 5:30 p.m., New York City time, on
Wednesday, August 29, 2001, unless the U.S. Offer is extended.
Your acceptance of the U.S. Offer is on the terms and subject to the
conditions contained in the U.S. Offer to Purchase and in this Form. In the
event of an inconsistency between the terms and procedures in the Form and the
U.S. Offer to Purchase, the terms and procedures in the U.S. Offer to Purchase
shall govern. Please contact the Information Agent at (800) 758-5880 to
discuss any inconsistency.
Do not detach any part of this Form
If you have any questions as to how to complete this Form, please
contact the Information Agent at (800) 758-5880 or (212) 269-5550.
Instructions
If you wish to accept the U.S. Offer you should:
(i) complete and sign this Form in accordance with the instructions set
out below;
(ii) forward this Form, together with the following documents to the
Receiving Agent at the address set forth on the back cover of the
U.S. Offer to Purchase:
(a) Titulo(s) evidencing ownership of Shares, if Shares are held in
certificated form,
(b) a certificate from the Company registry or the DCV evidencing the
number of Shares, if any, held on deposit at the DCV, the number
of shares held by the holder, and indicating the liens or
encumbrances that affect the Shares,
(c) duly signed Traspaso(s) (Exhibit 1) indicating the number of
Shares and the number of original issue Shares, if any, to be
tendered with the date of such Traspaso(s) in blank,
(d) in the case of Shares held on deposit at the DCV, a letter to the
DCV instructing the DCV to perform a book-entry transfer in favor
of the Purchaser; and
(e) in the case the U.S. holder is an individual, a copy of the U.S.
holder's passport or photo identification card,
(f) in the case the U.S. holder is an entity, (1) a Secretary's
certificate certifying the name, title and specimen signature of
an officer authorized to execute the transfer documents and a
copy of the entity's organizational documents, and (2) a copy of
the passport or photo identification card of the authorized
officer, and
(g) any other documents requested by the Receiving Agent to evidence
the authority of the U.S. holder to tender and sell its Shares;
and
(iii) ensure that they are sent so that they arrive or are delivered at
the address of the Receiving Agent not later than 5:30 p.m., New
York City time, on Wednesday, August 29, 2001, unless the U.S.
Offer is extended.
If the U.S. holder is acting through a power of attorney, a copy of such
power granted before a Notary Public in Chile or before the competent Chilean
General Consul must be provided to the Receiving Agent.
Power of Attorney
By accepting the U.S. Offer and signing this Form you hereby grant a
special irrevocable power of attorney to the Receiving Agent authorizing such
Receiving Agent to fill in the date in the Traspaso(s). By signing this Form
you hereby grant this irrevocable commercial power of attorney in the
understanding that it is being granted in the interest of both the principal
and the attorney-in-fact and that the attorney-in-fact shall not be liable for
rendering of accounts or any other obligations to you as principal. This
commercial power of attorney will be irrevocable unless this Form is revoked.
If this Form is revoked, this power of attorney shall be understood as
immediately revoked. This power of attorney revokes any and all sell orders of
the Shares and powers of attorney granted in connection thereto given
previously to this date.
Negative Covenant
By signing this Form, you agree that until the Expiration Date or until
your Shares are withdrawn from the Offer you will not sell, transfer, assign,
pledge or in any other way dispose of or encumber the Shares tendered hereby.
Representation
By signing this Form, you declare that your Shares tendered are fully
paid and free from liens and encumbrances.
How to complete this Form Please complete in BLOCK CAPITALS
- -------------------------------------------------------------------------------
1. The U.S. Offer
To accept the U.S. Offer, write in Box 1 the total number of Shares for
which you wish to accept the U.S. Offer. If no number, or a number greater
than your entire holding of Shares, is written in Box 1 and you have signed
Box 2, you will be deemed to have written the number of Shares comprised in,
and to have accepted the U.S. Offer in respect of, your entire registered
holding of Shares. To accept the U.S. Offer, complete Boxes 1 and 3 and, if
applicable, Box 4, and sign Box 2 below.
BOX 1
-----------------------------
---------------------------
Shares
2. Signatures
You must execute Box 2 and, in the case of a joint holding, arrange for
the designated common representative or, otherwise, all other joint holders to
do likewise.
In the case of joint holders, all must sign. All signatures must be
witnessed.
A witness should be a Chilean licensed stockbroker, a Notary Public in
Chile, competent Chilean General Consul or two individuals over 18 who are not
members of the tendering joint holders.
If you sign in a capacity other than that of a registered holder (e.g.,
under a Power of Attorney), please state the capacity in which you sign and
send together with this Form an authorized copy of the Power of Attorney duly
granted before a Notary Public in Chile or before the competent Chilean
General Consul.
Sign here to accept the U.S. Offer
BOX 2
- -------------------------------------------------------------------------------
Execution by Individuals Execution by a company
Signed and delivered as a deed by Executed and delivered as a deed of
In the presence
-------------------------------
----------------------------- -------------------------------
(Name of record holder)
-------------------------------
(Name of Company)
-----------------------------
(Signature of record holder) -------------------------------
-------------------------------
(The space above should be used to -------------------------------
witness as appropriate) (General Manager) (Signature)
-------------------------------
-------------------------------
-------------------------------
(Name of Secretary/Director)
(Signature)
3.Name(s) and address
Complete Box 3 with the full name and address of the sole or first named
registered holder together with the names of all other joint holders (if any)
in BLOCK CAPITALS.
Full name(s) and address
BOX 3
- ----------------------------------------------------------------------------------------------------------------
First registered Joint registered Joint registered Joint registered
holder Joint registered holder(s) holder(s) holder(s) holder(s)
1. First Name(s) 5.
________________ 2. First Name(s)_____ 3. First Name(s) ____ 4. First Name(s) ____ Corporation(s)__
Name of
(Mr./Mrs./Miss/Title) (Mr./Mrs./Miss/Title) (Mr./Mrs./Miss/Title) (Mr./Mrs./Miss/Title) Corporation
________________ _____________________ _____________________ _____________________ ________________
Last Name_______ Last Name ___________ Last Name ___________ Last Name____________ ________________
________________ _____________________ _____________________ _____________________ ________________
________________ _____________________ _____________________ _____________________ ________________
Address_________ Address______________ Address______________ Address______________ Address_________
________________ _____________________ _____________________ _____________________ ________________
Zip Code________ Zip Code_____________ Zip Code_____________ Zip Code_____________ Zip Code________
In case of questions please state daytime telephone number.
4.Alternative address
Insert in Box 4 the name and address of the person or agent (for
example, your bank) to whom you wish the consideration or returned documents
to be sent if not the same as in Box 3. Complete this Box if you wish the
consideration and/or other documents to be sent to someone other than the
first-named registered holder at the address set out in Box 3.
BOX
4
---------
Name ________________________________________
Address ________________________________________
________________________________________
________________________________________
________________________________________
Daytime telephone number ________________________________________
Additional notes regarding the completion and submission of this Form
In order to be effective, this Form must, except as mentioned below, be
executed personally by the registered holder or, in the case of a joint
holding, by the representative of ALL the joint holders as provided for in
Article 23 of Law 18.046 of the Chilean Companies Law and all signatures must
be independently witnessed as provided for in Article 15 of the Regulations of
the Chilean Companies Law (the "Rules"). A corporation must execute this Form
by means of an authorized officer.
1.If your Titulos(s) is/are held by your stockbroker, bank or some other agent
You should either obtain from your stockbroker, bank or other agent the
Titulos(s) in your name and submit it to the Receiving Agent together with the
Traspaso(s) with the date in blank and the Form duly signed with all the
documents indicated above or, alternatively, you should instruct your
stockbroker, bank or other agent to tender your Shares in the manner specified
above.
2. If you have lost any of your share certificates
The completed Form, together with any Titulo(s) which you have
available, should be sent to or delivered by hand to the Receiving Agent at
its address accompanied by a letter stating that you have lost one or more of
your Titulo(s). You should then follow the procedures provided for in Article
21 of the Rules and, when completed, ask the Company for a new Titulo.
3. If a holder is away from home (e.g., abroad or on holiday) or if this Form
is being signed under a Power of Attorney
Send this form by the quickest means (e.g., air mail) to the holder for
execution or, if the holder has executed a Power of Attorney, have this Form
signed by the Attorney. The completed Form together with the required
documents should be deposited with the Receiving Agent, at its address
accompanied by the Power of Attorney (or a duly certified copy thereof). Any
power of attorney must have been granted before a Notary Public in Chile or
before the competent Chilean General Consul. The Power of Attorney (or a duly
certified copy thereof) will be submitted for registration by the Receiving
Agent and returned as directed. No other signatures are acceptable.
4. If you have sold off all your holding
You should send this Form at once to the stockbroker, bank or other
agent through whom the sale was effected for transmission to the purchaser.
5.If you have any questions
You should immediately contact your stockbroker, bank or other agent or
the Receiving Agent.
The consideration due to you under the U.S. Offer cannot be sent to you
until all relevant documents have been properly completed and sent to or
deposited with the Receiving Agent. Notwithstanding that no Titulo(s) and/or
other document(s) of title is/are delivered with it, this Form, if otherwise
valid, accompanied by the appropriate endorsement or certificate signed on
behalf of the transfer agent of the Company will be treated as a valid
acceptance of the U.S. Offer.
EXHIBIT 1
TRASPASO DE ACCIONES PRIMERA EMISION
Senor Gerente de: LABORATORIO CHILE S.A.
Sirvase Ud. hacer traspasar ____________________________________________________
________________________________________________________________________________
acciones de LABORATORIO CHILE S.A. de mi propiedad, segun titulos No ___________
las que he enajenado a _________________________________________________________
al precio de US$ 1,25 .-
pagadero en pesos Chilenos, conforme al tipo de cambio de Ch$629.00 por
US$1.00.
TESTIGOS En , a de de 2001
Mayores de Edad __________________________________________
NOMBRE
_________________________ NOMBRE DEL VENDEDOR
R.U.T.
_________________________ __________________________________________
DOMICILIO
_________________________ FIRMA DEL VENDEDOR O REPRESENTANTE
_________________________
R.U.T. No ______________________________
FIRMA
_________________________ DOMICILIO ______________________________
COMUNA ______________________________
NOMBRE
_________________________
_________________________ CIUDAD _________________ FONO_______
R.U.T.
_________________________ CASILLA _________________ E.CIVIL
_____
DOMICILIO
_________________________ NACIONALIDAD_________________
_________________________ CONYUGE ______________________________
FIRMA
_________________________
- --------------------------------------------------------------------------------
Por el presente instrumento, acepto el traspaso precedente y asimismo los
estatutos de LABORATORIO CHILE S.A.
- --------------------------------------------------------------------------------
TESTIGOS En , a de de 2001
Mayores de Edad
NOMBRE
_________________________ FIRMA COMPRADOR O REPRESENTANTE
R.U.T.
_________________________
DOMICILIO
_________________________ R.U.T. No ______________________________
_________________________ DOMICILIO ______________________________
COMUNA ______________________________
FIRMA
_________________________ CIUDAD _________________ FONO_______
CASILLA _________________ E.CIVIL
_____
NOMBRE
_________________________
_________________________ NACIONALIDAD_________________
R.U.T.
_________________________ CONYUGE ______________________________
DOMICILIO
_________________________
_________________________
FIRMA
_________________________
ADQUIRENTE O COMPRADOR SOLICITA
- --------------------------------------------------------------------------------
1- Que la sociedad tenga a su disposicion el titulo
correspondiente a las acciones adquiridas o compradas, dentro
del plazo de 6 dias habiles desde la fecha de recepcion del
traspaso.
[_]
2- Que la sociedad no emita el titulo en el plazo establecido en
el No 1 precedente, sin perjucio de la inscripcion del traspaso
correspondiente, y del derecho a solicitar el titulo cuando lo
considere oportuno.
[_]
Esta nota se transcribe en virtud de lo estipulado en la circular
No 1.494 de la S.V.S. de fecha 17 de Agosto de 2000.
PARA USO INTERNO DE LA COMPANIA
- --------------------------------------------------------------------------------
SE CANCELO--SE SALDO SE EMITIO
Titulo No por Titulo No por acciones
acciones
- --------------------------------------------------------------------------------
Fecha de recepcion: Santiago, de de 2001
---------------------
FIRMA AUTORIZADA
NOTA : Por instrucciones impartidas en circular No 585 de fecha 29 de Enero
de 1986 de la S.V.S., el presente traspaso debera ser presentado a la
Sociedad para su inscripcion en el menor plazo posible.
Importante: FIRMA: ______________________________
R.U.T.: ______________________________
Todo comprador debera firmar este recorte
Se encarece el cumplimiento de esta exigencia
Domicilio: ______________________________
por ser indespensable para el registro de firmas.
Comuna: _________________ Ciudad:
______
TRASPASO DE ACCIONES
Senor Gerente de: LABORATORIO CHILE S.A.
Sirvase Ud. hacer traspasar ____________________________________________________
________________________________________________________________________________
acciones de LABORATORIO CHILE S.A. de mi propiedad, segun titulos No ___________
las que he enajenado a _________________________________________________________
al precio de US$ 1,25 .-
pagadero en pesos Chilenos, conforme al tipo de cambio de Ch$629.00 por
US$1.00.
TESTIGOS En , a de de 2001
Mayores de Edad __________________________________________
NOMBRE
_________________________ NOMBRE DEL VENDEDOR
R.U.T.
_________________________ __________________________________________
DOMICILIO
_________________________ FIRMA DEL VENDEDOR O REPRESENTANTE
_________________________
R.U.T. No ______________________________
FIRMA
_________________________ DOMICILIO ______________________________
COMUNA ______________________________
NOMBRE
_________________________
_________________________ CIUDAD _________________ FONO_______
R.U.T.
_________________________ CASILLA _________________ E.CIVIL
______
DOMICILIO
_________________________ NACIONALIDAD_________________
_________________________ CONYUGE ______________________________
FIRMA
_________________________
- --------------------------------------------------------------------------------
Por el presente instrumento, acepto el traspaso precedente y asimismo los
estatutos de LABORATORIO CHILE S.A.
- --------------------------------------------------------------------------------
TESTIGOS En , a de de 2001
Mayores de Edad
NOMBRE
_________________________ FIRMA COMPRADOR O REPRESENTANTE
R.U.T.
_________________________
DOMICILIO
_________________________ R.U.T. No ______________________________
_________________________ DOMICILIO ______________________________
COMUNA ______________________________
FIRMA
_________________________ CIUDAD _________________ FONO_______
CASILLA _________________ E.CIVIL
______
NOMBRE
_________________________
_________________________ NACIONALIDAD_________________
R.U.T.
_________________________ CONYUGE ______________________________
DOMICILIO
_________________________
_________________________
FIRMA
_________________________
ADQUIRENTE O COMPRADOR SOLICITA
- --------------------------------------------------------------------------------
1- Que la sociedad tenga a su disposicion el titulo
correspondiente a las acciones adquiridas o compradas, dentro
del plazo de 6 dias habiles desde la fecha de recepcion del
traspaso.
[_]
2- Que la sociedad no emita el titulo en el plazo establecido en
el No 1 precedente, sin perjucio de la inscripcion del traspaso
correspondiente, y del derecho a solicitar el titulo cuando lo
considere oportuno.
[_]
Esta nota se transcribe en virtud de lo estipulado en la circular
No 1.494 de la S.V.S. de fecha 17 de Agosto de 2000.
PARA USO INTERNO DE LA COMPANIA
- --------------------------------------------------------------------------------
SE CANCELO--SE SALDO SE EMITIO
Titulo No por Titulo No por acciones
acciones
- --------------------------------------------------------------------------------
Fecha de recepcion: Santiago, de de 2001
---------------------
FIRMA AUTORIZADA
NOTA : Por instrucciones impartidas en circular No 585 de fecha 29 de Enero
de 1986 de la S.V.S., el presente traspaso debera ser presentado a la
Sociedad para su inscripcion en el menor plazo posible.
Importante: FIRMA: ______________________________
R.U.T.: ______________________________
Todo comprador debera firmar este recorte
Se encarece el cumplimiento de esta exigencia
Domicilio: ______________________________
por ser indespensable para el registro de firmas.
Comuna: _________________ Ciudad:
______
EXHIBIT 1
PLEASE NOTE THAT THIS ENGLISH LANGUAGE TRANSLATION OF "TRASPASO DE ACCIONES"
IS PROVIDED FOR YOUR INFORMATION ONLY.
TO BE EFFECTIVE, THE ORIGINAL SPANISH LANGUAGE TRASPASO MUST BE COMPLETED AND
SIGNED.
TRANSFER OF SHARES (for information purposes only)
I hereby advise the manager of: LABORATORIO CHILE S.A.
to transfer ________________________________________________________________
_____________________________________________________________________________
shares of LABORATORIO CHILE S.A. of my own, as recorded in certificate No. __
and which I have conveyed to _______________________________________________
at a price of US$ 1.25 .-
payable in Chilean pesos, calculated at Ch$629.00 per US$1.00.
In on , 2001
WITNESSES
18 years old or older __________________________________________
NAME_________________________ NAME OF SELLER
PASSPORT __________________________________________
OR ID NO.
_________________________ SIGNATURE OF SELLER OR SELLER'S AGENT
ADDRESS
_________________________ PASSPORT
_________________________ OR ID NO. _____________________________
ADDRESS _____________________________
SIGNATURE
_________________________ CITY _____________________________
STATE _______________ PHONE_______
NAME_________________________ P.O. BOX ________ MARITAL STATUS
_______
PASSPORT NATIONALITY _________________
OR ID NO.
_________________________ NAME OF SPOUSE
_____________________________
ADDRESS
_________________________
_________________________
SIGNATURE
_________________________
- -------------------------------------------------------------------------------
I hereby accept the above transfer as well as the bylaws of LABORATORIO CHILE
S.A.
- -------------------------------------------------------------------------------
WITNESSES In on , 2001
18 years old or older
__________________________________________
NAME_________________________ SIGNATURE OF BUYER OR BUYER'S AGENT
PASSPORT
OR ID NO.
_________________________ PASSPORT
ADDRESS
_________________________ OR ID NO. _____________________________
_________________________ ADDRESS _____________________________
CITY _____________________________
SIGNATURE
_________________________ STATE _______________ PHONE_______
P.O. BOX ________ MARITAL STATUS
_______
NAME_________________________ NATIONALITY _________________
PASSPORT NAME OF SPOUSE
_____________________________
OR ID NO.
_________________________
ADDRESS
_________________________
_________________________
SIGNATURE
_________________________
- -------------------------------------------------------------------------------
ACQUIRER OR BUYER REQUESTS:
- -------------------------------------------------------------------------------
1- That the company make the certificate for the purchased or
acquired shares available no later than 6 business days
following the date of receipt of the notice of transfer.
[_]
2- That the Company not issue the certificate within the term
specified under No. 1, above, without detriment to registration
of the transfer and the right to request the certificate in due
course.
[_]
This notice is made under the provisions stipulated in Memorandum
No. 1.494 issued by the Superintendency of Securities and
Insurance on August 17, 2000.
FOR INTERNAL COMPANY USE
SETTLED--PAID IN ISSUED
Certificate No. for Certificate No. for
shares shares
- -------------------------------------------------------------------------------
Date of receipt in , on , 2001
---------------------
AUTHORIZED SIGNATURE
Note: according to the instructions set forth in memorandum No. 585 issued by
the Superintendency of Securities and Insurance on January 29, 1986, this
transfer of shares must be presented to the Company for registration without
delay.
Important: SIGNATURE:_____________________________
All buyers must sign this form PASSPORT
OR ID NO.:_____________________________
Compliance with this requirement is strongly recommended,
Street Address:
as it is required for the Signature Registry _____________________________
City: ________________ State:
_______
TRANSFER OF NEWLY ISSUED SHARES (for information purposes only)
I hereby advise the manager of: LABORATORIO CHILE S.A.
to transfer ________________________________________________________________
_____________________________________________________________________________
shares of LABORATORIO CHILE S.A. of my own, as recorded in certificate No: __
and which I have conveyed to _______________________________________________
at a price of US$ 1.25 .-
payable in Chilean pesos, calculated at Ch$629.00 per U.S.$1.00.
In on , 2001
WITNESSES
18 years old or older __________________________________________
NAME_________________________ NAME OF SELLER
PASSPORT __________________________________________
OR ID NO.
_________________________ SIGNATURE OF SELLER OR SELLER'S AGENT
ADDRESS
_________________________ PASSPORT
_________________________ OR ID NO. _____________________________
ADDRESS _____________________________
SIGNATURE
_________________________ CITY _____________________________
STATE _______________ PHONE_______
NAME_________________________ P.O. BOX ________ MARITAL STATUS
_______
PASSPORT NATIONALITY _________________
OR ID NO.
_________________________ NAME OF SPOUSE
_____________________________
ADDRESS
_________________________
_________________________
SIGNATURE
_________________________
- -------------------------------------------------------------------------------
I hereby accept the above transfer as well as the bylaws of LABORATORIO CHILE
S.A.
- -------------------------------------------------------------------------------
WITNESSES In on , 2001
18 years old or older __________________________________________
SIGNATURE OF BUYER OR BUYER'S AGENT
NAME_________________________
PASSPORT PASSPORT
OR ID NO.
_________________________ OR ID NO. _____________________________
ADDRESS
_________________________ ADDRESS _____________________________
_________________________ CITY _____________________________
STATE _______________ PHONE_______
SIGNATURE
_________________________ P.O. BOX ________ MARITAL STATUS
_______
NATIONALITY _________________
NAME_________________________ NAME OF SPOUSE
_____________________________
PASSPORT
OR ID NO.
_________________________
ADDRESS
_________________________
_________________________
SIGNATURE
_________________________
- -------------------------------------------------------------------------------
ACQUIRER OR BUYER REQUESTS:
- -------------------------------------------------------------------------------
1- That the company make the certificate for the purchased or
acquired shares available no later than 6 business days
following the date of receipt of the notice of transfer.
[_]
2- That the Company not issue the certificate within the term
specified under No. 1, above, without detriment to registration
of the transfer and the right to request the certificate in due
course.
[_]
This notice is made under the provisions stipulated in Memorandum
No. 1.494 issued by the Superintendency of Securities and
Insurance on August 17, 2000.
FOR INTERNAL COMPANY USE
SETTLED--PAID IN ISSUED
Certificate No. for Certificate No. for
shares shares
- -------------------------------------------------------------------------------
Date of receipt in , on , 2001
---------------------
AUTHORIZED SIGNATURE
Note: according to the instructions set forth in memorandum No. 585 issued by
the Superintendency of Securities and Insurance on January 29, 1986, this
transfer of shares must be presented to the Company for registration without
delay.
Important: SIGNATURE:_____________________________
All buyers must sign this form PASSPORT
OR ID NO.:_____________________________
Compliance with this requirement is strongly recommended,
Street Address:
as it is required for the Signature Registry _____________________________
City: ________________ State:
_______
PAYER'S NAME: The Bank of New York
Part 1--PLEASE PROVIDE YOUR Social security
SUBSTITUTE TIN IN THE BOX AT THE RIGHT number or Employer
Form W-9 AND CERTIFY BY SIGNING AND identification
Department of DATING BELOW. number
the Treasury
Internal ------------------
Revenue Service
-----------------------------------------------------
Part 2--Awaiting TIN [_]
Payer's Request for
Taxpayer Identification
Number (TIN)
- --------------------------------------------------------------------------------
Part 3--CERTIFICATION--Under the penalties of perjury, I certify that:
(1) The number shown on this form is my correct Taxpayer Identification
Number (or I am waiting for a number to be assigned to me), and
(2) I am not subject to backup with holding because: (a) I am exempt from
backup withholding, or (b) I have not been notified by the Internal
Revenue Service (the "IRS") that I am subject to backup withholding as a
result of a failure to report all interests or dividends, or (c) the IRS
has notified me that I am no longer subject to backup withholding.
Certification Information--You must cross out Item (2) above if you have
been notified by the IRS that you are temporarily subject to backup
withholding because of under-reporting interest or dividends on your tax
returns. However, if after being notified by the IRS that you were subject
to backup withholding you received another notification from the IRS that
you are no longer subject to backup withholding, do not cross out such Item
(2).
Name ________________________________________________________________________
(Please Print)
Address _____________________________________________________________________
(Including Zip Code)
Signature _________________________________ Date ___________________________
YOU MUST COMPLETE THE FOLLOWING CERTIFICATE IF YOU CHECKED THE BOX
IN PART 2 OF SUBSTITUTE FORM W-9
CERTIFICATE OF AWAITING TAXPAYER IDENTIFICATION NUMBER
I certify under penalties of perjury that a taxpayer identification number
has not been issued to me, and either (a) I have mailed or delivered an
application to receive a taxpayer identification number to the appropriate
Internal Revenue Service Center or Social Security Administration Office or
(b) I intend to mail or deliver an application in the near future. I
understand that, notwithstanding that I have checked the box in Part 2 (and
have completed this Certificate of Awaiting Taxpayer Identification Number),
all reportable payments made to me prior to the time I provide the Receiving
Agent with a properly certified taxpayer identification number will be
subject to a 31% back-up withholding tax.
Signature _________________________________ Date ___________________________
NOTE: FAILURE TO COMPLETE AND RETURN THIS SUBSTITUTE FORM W-9 MAY RESULT IN
BACK-UP WITHHOLDING OF 31% OF ANY CASH PAYMENT MADE TO YOU PURSUANT
TO THE U.S. OFFER. PLEASE REVIEW THE ENCLOSED GUIDELINES FOR
CERTIFICATION OF TAXPAYER IDENTIFICATION NUMBER ON SUBSTITUTE FORM W-
9 FOR ADDITIONAL DETAILS.