APPLICATION FORM
FOR EQUITY SHARES

STAR LAGOON HEALTH RESORTS & TOURISM PRIVATE LIMITED

Incorporated on 4th October 2005 under the Companies Act 1956
Reg. Off : Door No. 8/342, “Bhadranjali”, Pallathampully, Tattamangalam. P.O., Palakkad District, Kerala – 678 102.

Dear Sirs,
On the basis of the Company’s Offer Document, I/We hereby apply to you for allotment of the Equity Shares to me/us stated below. The amount payable on application as shown below is remitted herewith. I/We hereby agree to accept the Equity Shares applied for, or such lesser number of equity shares as may be allotted to me/us. I/We undertake that I/we will sign all such other documents and do all such other acts, if any , necessary on my/our part to enable me/us to be registered as the holder(s) of the Equity Shares that may be allotted to me/us.  I/we authorize you to place my/our names (s) on the Register of Members of the Company as holders of the Equity Shares that may be allotted to me/us and register my/our address(es) as give below. I/We note that the Board of Directors are entitled in their absolute discretion to accept or rejects the application in whole or part without assigning any reason whatsoever. In the event, the amount paid by me us not correct, I/we understand that this application will be rejected

I/We confirm that: (Thick whichever is applicable)

I am / We are Indian National(s) resident in India and I am/we are not applying for said Equity Shares as nominee of any person resident out side India or foreign national (s)

I/We are Indian national (s) resident in India and I am/we are applying for said as Power of Attorney holder(s) of NRIs mentioned below on non-repartiation basis.

I/We Confirm that I/we have not received and will not receive any commission or brokerage or any other incentive in any form, directly or indirectly, for subscribing to the issue.

No. of Equity Shares applied for

Amount paid (Rs.)

Cash / Cheque / DD No.

In Figures

In Words

In Figures

In Words

NAME IN FULL
(Mr./Mrs./Ms.)

ADDRESS

PIN CODE

PAN NUMBER

FATHER'S / HUSBAND'S NAME IN FULL

Age

Occupation

Date of Birth (DD/MM/YYYY)

AGE

AGE

NAME IN FULL
(Mr./Mrs./Ms.)

ADDRESS

PIN CODE

Date of Birth
(If minor)

Name of Gurdian

Date of Signing
(DD/MM/YYYY)

SOLE / FIRST APPLICANT

SECOND APPLICANT

THRIRD APPLICANT

 SIGNATURE OF THE APPLICANT (S)