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แบบแจ้งชื่อผู้บริหารของบริษัท Powered By Docstoc
					                                                  Unofficial translation prepared by Legal Department


                                                                                       FORM 35-E1
                      Information of the Company’s Director and Executive
                                        [company’s name]
                             filed on

Position in the Company
    Director
    [ ] President
    [ ] President Independent Director and Member of Audit Committee
    [ ] President and Independent Director
    [ ] Director
    [ ] Independent Director
    [ ] Independent Director and Member of Audit Committee
    Executive
    [ ] Executive (please specify title in the company)

Date of Appointment :

Part 1 : General Information
1.1 First name / Last name (in Thai) :
    Title        First Name                       Last name
    First name / Last name (in English) :
    Title        First Name                       Last name
    Old First name / Last name (if any) (in Thai)
    Title        First Name               Last name                       Date of Change
    Old First name / Last name (if any) (in English)
    Title        First Name               Last name                        Date of Change
    (Please specify all information on change of first name / last name since becoming sui juris
   and also attach documents indicating such change)

1.2 Type of Card
    [ ] Identification Card
    [ ] Passport (only for non-Thai national who does not have an identification card or does not
        know identification number)
     Card Number :                              Expiry Date :
    (Please attach a copy of identification card or passport)

1.3 Nationality :

1.4 Date of Birth :
                                               2


                                             [specify director or executive’s first and last names]

1.5 Current Address :
    #                                              Village / Building
   Moo                                         Trok / Soi
   Road                                        Sub-district
   District                                    Province
   Zip Code                                    Country
   Tel.                                        Fax.
   E-mail
   Overseas Address : (only for a non-Thai national, please specify overseas contact address)




1.6 Academic Background
    Highest Degree : [ ] Lower than Bachelor Degree [ ] Bachelor Degree and higher
    Major :                             Name of Institution :
    Related academic background in case of member of audit committee
    (Bachelor Degree or higher):
    [ ] Accounting                    Name of Institution:
    [ ] Finance                       Name of Institution:

1.7 Related training programs held by the Thai Institute of Directors Association (IOD)
                Name of Program                                          Year of Attendance
    [ ] Director Certification Program (DCP)
    [ ] Director Accreditation Program (DAP)
    [ ] Audit Committee Program (ACP)
    [ ] Finance for Non-Finance Director (FN)
    [ ] The Role of Chairman (RCP)
    [ ] Understanding the Fundamental of Financial Statements (UFS)
    [ ] Role of the Compensation Committee (RCC)
    [ ] Improving the Quality of Financial Reporting (QFR)
    [ ] DCP Refresher Course
    [ ] others (please specify)
                                                  3


                                            [specify director or executive’s first and last names]

Part 2 : Prohibited Characteristics
    (1) has been subject to the court’s receiving order or declared by any       [ ] Yes [ ] No
    court as an insolvent person, an incompetent or a quasi-incompetent
    person.
    (2) having been prohibited from being a director, an executive or a          [ ] Yes [ ] No
    controlling person of a listed company by the Stock Exchange of
    Thailand.
    (3) has been denounced or has been tried in any criminal proceedings         [ ] Yes [ ] No
    instituted by authorities in the offences of unfair trading practices in
    securities or derivatives, or fraudulent or dishonest management.
    (4) is being barred from serving as company’s director or executive          [ ] Yes [ ] No
    by foreign authority.
    (5) was convicted by the court’s final judgment or fined on any count        [ ] Yes [ ] No
    of offenses as specified in (3).

     Apart from prohibited characteristics mentioned above, I hereby acknowledge that, for
the purpose of rendering consideration whether to list my name onto the Director and Executive
Database, the SEC Office will also take following prohibited characteristics into account:
     (1) has or used to have any behavior, that if considered on reasonable ground, indicates
failure to discharge properly the duty of loyalty or duty of care for the best interest of the
company and shareholders of the company, or aids or abets or used to aid or abet the others in
connection with such behavior.
     (2) has or used to have any behavior, that if considered on reasonable ground, indicates
dishonest to or defraud the others, or aids or abets or used to aid or abet the others in connection
with such behavior.
      (3) has or used to have any behavior, that if considered on reasonable ground, indicates
unfair practices or disadvantage the investors, or aids or abets or used to aid or abet the others in
connection with such behavior.
      (4) has or used to have any behavior, that if considered on reasonable ground, indicates
concealment of the actual financial conditions or the result of operation of any listed company or
any company offered securities for sale to the public, or making any material false statement, or
omission of any material fact which should have been expressly disclosed in order to make such
statement not misleading, in any document required to be disclosed to public or filed with the
SEC Office, the Capital Market Supervisory Board or the SEC, regardless of whether such act
was carried out in my own capacity or on behalf of others, or aids or abets or used to aid or abet
the others in connection with such behavior.
      (5) has or used to have any behavior, that if considered on reasonable ground, indicates
failure to discharge properly the duty to supervise as the company’s director,executive or
controlling person, with a view to preventing violation of laws, company’s objectives or bylaws,
or its shareholders’ resolutions by the company and its subsidiaries, the result of which may
adversely affect trustworthiness in capital market as a whole or reputation, status or business
operation of such company.
                                                4

                                            [specify director or executive’s first and last names]

Part 3 : Representation and Warranty

3.1 Director and Executive’s Representation and Warranty
    (a) I have given the company my personal information as stated above and hereby represent
    and warrant that all information and supplementary documents are true and complete and
    do not contain any false statement or omit any fact that should have been expressly disclosed
    in material respects; and
    (b) I hereby acknowledge and give my permission on use information disclosed in this
    document for the purpose of rendering consideration whether to list my name onto the
    Director and Executive Database provided by the SEC Office. And I hereby give my
    permission to the SEC Office to disclose to the company and person appointed by the
    company the information as to whether I have any prohibited characteristics.
    (c) I hereby acknowledge that -
        1. The SEC Office will list my name onto the Director and Executive Database only if
           there is no reasonable ground to suspect that I have any prohibited characteristics.
        2. Listing of my name onto the Director and Executive Database destines solely for the
          purpose of consideration on the issuing company’s qualification and will not, in any
          event, warrant that I do not have any prohibited characteristics. In addition, the listing
          thereof will not be deemed as giving approval to the director and executive of the
          company.
       3. Where it is apparent to the SEC Office that I have prohibited characteristics, the SEC
           Office may de-list my name from the Director and Executive Database. Besides, the
           SEC Office will de-list my name from the Director and Executive Database upon the
           death or vacating from the position in the company or upon the retirement of
           obligation of the company where I hold position or work as to preparation and
           submission of report on financial condition and result of operation under Section 56 of
           the Securities and Exchange Act B.E. 2535 (1992). In case of vacating from the
           position in one company, the SEC Office may not de-list my name, if I remain
           holding position in or working for the other company also filing with the SEC Office
           my information for listing onto the Director and Executive Database.



                                Name                     Title                  Signature
                                                       5

                                                  [specify director or executive’s first and last names]

3.2 The Company’s Representation and Warranty
    The company has reviewed the information stated in this Information of Company’s Director
    and Executive and found no reasonable ground to believe that information and supplementary
    documents are not true and complete and contain any false statement or omit any fact that
    should have been expressly disclosed in material respects

        In this regard, the company has appointed
as a coordinator for information relating to the said director and executive.

                                     Name                       Title                   Signature*

1.

2.




        *
            Authorized signatory of the company shall sign this Form and affix the corporate seal hereto (if any)

				
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