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The Asia Gold Mining Asset Corporation (AGMAC) Skyper Villa,

Taunusanlage 1,

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:




Zip/Post Code:


I can be reached at:

Mobile Number:

Land Line Phone Number:

Fax Number:

Email Address:

I prefer to be reached by: Email

Mobile Phone

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.



Date: ____ Day _____ Month _____ Year

*Cross out whichever is not applicable

*Fill up in BLOCK LETTERS only