I am authorised by the Board of Directors of the company vide resolution number ___________ dated ___________ to sign this form and declare that all the requirements of the Companies Act, 2013 and the rules made thereunder in respect of the subject matter of this form and matters incidental thereto have been complied with. Whatever is stated in this form and in the attachments thereto is true, correct and complete and no information material to the subject matter of this form has been suppressed or concealed and is as per the original records maintained by the promoters subscribing to the Memorandum of Association and Articles of Association. It is further declared and verified that all the required attachments have been completely, correctly and legibly attached to this form.

SignedDate:

Place:

Attachments:-

• Copy of Board resolution

• Copy of shareholders resolution

• Copy of ..............................

• Optional attachments, if any.

Form PAS-5

[see rule 14(4)] [Substituted '(Section 42(7) and Rule 14(3) of Companies (Prospectus and Allotment of Securities) Rules, 2014)' by Notification No. G.S.R. 752(E), dated 7.8.2018 (w.e.f. 31.3.2014).]

Record of a private placement offer to be kept by the company

Name of the Company:

Registered office of the Company:

CIN:

Details of Private Placement Offer :

Date when approval of the relevant authority (board or the shareholders, as the case may be) obtained for the current Private Placement Offer Letter :

Amount of the offer:

Date of circulation of private placement offer letter:

Following details (in a tabulate statement) of the persons to whom private placement offer letter has been circulated :-

(i) Name

(ii) Father's name

(iii) Complete Address including Flat/House Number, Street, Locality, Pin Code

(iv) Phone number, if any