INDIVIDUAL INFO PAGE - Mr. Akira Tabata

Commercial Bank of Ceylon PLC operated jointly and for guardian {parent/legal guardian} when account krolder is minon L, Narne of the lndividual -TJtrTdFI AccountNo trtrtrtrtrtrtrIItr CFNOtrtrtrtrtrtrEtrEtr rtrtrtrTItrtrtrItrtrtrtrtrIIItrtr ETtrtrtrEtrtrTtrItrTtrtr[]trtr[]tr trItrtrtrtrtrtr (DD/MM/YYYY) 2. Date cf Birth q?SffiEt 3. Relationship with AIC ffifffi qf6ql q*?fd tl znd Applicant - E<lqlr<aercI-A t Fartner - elrfliTlR tr Guardian - qtrsf<e il Beneficial Os,vne r - ffifu-ft-g'1-q r3dl-E X 3rd Applicant - oTqffi f tr Pr"oprietor - qre-<F qpfffi tl tr Attorney Holder - €ffi CqiEK ft U Trustee $fm f, Others - qffiT Photograph of the lntiiviciual qfunrfrf Director - "|RDI Ts Minor - dFIlcr<F" AIC Operator - ful-<"iffi a) EtqeK b) !n EngNish Bloe k l-etter 4. Father's Name (tn Block Letteri flnsrs ffi 5. fUother's Na me (ln Block Letter) illEl{ rylr{ 6. Spouse Na me (ln Block Ler[er) qlffiiffirdH 7. N afiona trity :' qiffi g. Gender ffi 1"0. 0ccupation (tn Detaii) c",i,.fi(ffi) 12. fMonthly lncome EIftSW{ 1,4. Present Address T6frH ft$FTI 15. Pes'manent Address qLftffiT.mr 16. Credentia ls "tRDft "lq tr Mlale - Trq il Female - npgl il Others - q-dfffl' 8. Residential Status: qKItr-Tq{q r Resident-ffi 11". eTlN (tr Available) ?-ffi ({ft Errs) n Non-Resident - qffi 13. Soruce of Fund (ln Deriat) qr{rGsq(ffi) [-!ouse - qiE Dist.-G?11 Apt.- q"tffr Block -ffi h/lobile -GlqR-d Thana - qiht Post Code - 6ffi6Afs Country - eryf Phone - FlT Ernail (ln tslock Letten)- -q-fffin House -ffi Dist.-GQl Apt.- €'Xffi Block -ffi Thana - qd Post Code - 6ffi69M Country -Cq{ Fhone/Mob No" - eFfdfinffi{q a) b) c) National tD Number - tr.]frT "lRFS"iq dqf< Passport No./ Birth Registration Nc. - "ffq-Cqffi/ G?-{ fi--{t-{ Tq'T others (Flease Specify) - q-fffl (ft,ffiq6 s1gq SEC6" q;q) Signature - EITFTil l Anyindentitycardwhichisocceptobletothebonk@nsideinglinonciolinclusion- tfuilfrwwfiFtl,dLratrfr@@Ezwclc#t,ta6fuep 2 Fot loreign ndtional copy of Passport including Wsa must be obtoined -f\qlqilMtWffiqrlw?kfrcFlq4wqMqwo@ 3 Guidelin$hrForExtronsodionto befollowedwhen required -ffitc*qAFqE{o7@rtWWw,Wwl@dYSiffin4lw<1 Date - ur#{ t\ ✓ A K I R A T A B A T A TOKIO TABATA MIYO TABATA N/A J apanese ✓ ✓ ✓ Service N/A 0 5 0 3 1 9 7 0 +81 80 8760 6629 +81 80 8760 6629 A.TABATA@TOYOSHIMA.CO.JP TM0632243 Japan Japan 13-3,Fujikacho,Meito-ku,Aichi, JAPAN 13-3,Fujikacho,Meito-ku,Aichi,JAPAN