E-mail address Telephone number Fax number Mobile phone number 2. Principal place of practice Firm Name Position in the firm Address City State Postcode Country E-mail address Telephone number Fax

rights and warrants 22. Additional paid-in capital (discount on capital stock)) 23. Appraisal surplus 24. revaluation surplus (deficit) in investments) 25. Retained earnings (deficits) arising from risk

preparation and submission of daily status report in text file via OFAR Version 1.7 Intermediaries Supervision Policy Department Telephone: 0-2263-6257 Facsimile: 0-2263-6487

_______ Country _______ Expiry date _______ Home Address _______ City State Postcode Country E-mail address Telephone number Fax number Mobile phone number 2. Principal place of practice Firm Name Position

........ Year ............. Year ............. Year ............ Total assets Total liabilities Shareholders’ equity Total income Cost Net profits Earnings per share (EPS) Debt/equity ratio (D/E ratio) Return on

comply with the requirements accordingly. Sincerely -signature- (Mr. Vorapol Socatiyanurak) Secretary-General Intermediaries Supervision and Development Department Telephone: 0-2263-6255 Fax: 0-2263-6446

: ......................... Sub-district: ................. District: ...................... Province: .................. Telephone: ................................................... Facsimile

made by an authorised person and examining of the correctness of the cheque preparation. 4. There should be a dividend payment system e.g. an allocation of the retained earnings and the list of

) ………………………………………………………… Location of head office ……………………………………………………………… …………………………………………………………………..…………………… Telephone number …………………….. Facsimile number ……………………….. Part 2: Category of an applicant □ A commercial bank under the

…………................................................................. …………………………….......................................................................... telephone number…………………….. facsimile number ………………………… 2. Details for supplementing the consideration: 2.1 A license granted by the authorized organization or agency under the law (only in the case of a CB