India Glycols : Form ISR-3

Form ISR ‐ 3

Declaration Form for Opting‐out of Nomination by holders of physical securities in Listed

Companies

(see SEBI circular No. SEBI/HO/MIRSD/MIRSD_RTAMB/P/CIR/2021/655 dated November 03, 2021 on Common and Simplified Norms for

processing investor's service request by RTAs and norms for furnishing PAN, KYC details and Nomination)

[Under Section 72 r/w Section 24 (1) (a) of Companies Act, 2013 r/w Section 11(1) and 11B of SEBI Act, 1992 and Clause C in Schedule VII and Regulation 101 of SEBI (Listing Obligations and Disclosure Requirements) Regulations, 2015)]

To,

India Glycols Limited

CIN: L24111UR1983PLC009097

A‐1, Industrial Area, Bazpur Road, Kashipur‐ 244 713,

Dist. Udham Singh Nagar Uttarakhand

I / we ……………………… the holder(s) of the securities particulars of which are given hereunder, do not

wish to nominate any person(s) in whom shall vest, all the rights in respect of such securities in the event of my /our death.

PARTICULARS OF THE SECURITIES (in respect of which nomination is being opted out)

Nature of Folio No. No. of Securities Certificate No. Distinctive No. Securities

I/ we understand the issues involved in non‐appointment of nominee(s) and further are aware that in case of my / our death, my / our legal heir(s) / representative(s) are required to furnish the requisite documents / details, including, Will or documents issued by the Court like Decree or Succession Certificate or Letter of Administration / Probate of Will or any other document as may be prescribed by the competent authority, for claiming my / our aforesaid securities.

Sole / First Holder Name

Second Holder Name

Third Holder Name