The Asia Gold Mining Asset Corporation (AGMAC) Skyper Villa,
60329 Frankfurt am Main, Germany.
AGMAC Shareholder Declaration Form - 118A/5/13
I, Mister/Miss* AYU YUDHINI, a holder of Indonesia Passport/National Identification Card* Number 32.0428.540287.0019, date of expiry on ____________ (if applicable) hereby declare that I am the sole beneficiary of all AGMAC shares and options as stated in my online shareholder account number 100001982545.
I also declare that, my permanent address is:
I can be reached at:
Land Line Phone Number:
I prefer to be reached by: Email
The best time to reach me is between: ______ and _______ (local time)
I declare that all the information provided above is true to my knowledge, and that I will be held accountable should I purposely provide false information.
Signature AYU YUDHINI
Date: ____ Day _____ Month _____ Year
*Cross out whichever is not applicable
*Fill up in BLOCK LETTERS only