CAPITA Share Order Form

SECURITIES SALE / PURCHASE TRADE ORDER FORM

Customer ID#:

Date Order Received:

Time Order Received:

Time Order Executed:

Time Order Cancelled:

Please Select:

Please SELL

PURCHASE

on MY / OUR behalf

ACCOUNT HOLDER

Name

Prefix First Middle Last Maiden Name (if applicable)

Place of Birth

Residential Address

Street & Avenue Years (at Residence) City / Town Parish / State ZIP / Postal Code Country

Home Phone

Mobile Phone

TRADE ORDER DETAILS

CSD ID#:

CSD ACCOUNT#:

1. Security Project

Security Name Security Symbol Quantity Limit Price (BDS)

1. Projected Cost (BDS)

2. Security Project

Security Name Security Symbol Quantity Limit Price (BDS)

2. Projected Cost (BDS)

3. Security Project

Security Name Security Symbol Quantity Limit Price (BDS)

3. Projected Cost (BDS)

Total Projected Cost

Add: Commission / Mark-up

Add: Transaction Changes

Total Projected Settlement Amount

ORDER MODIFICATION PARAMETERS SET BY CUSTOMER (OPTIONAL)

Order Modified To:

Agent Responsible for Modification:

PAYMENT OPTION

Type of Payment

Local Cheque

Wire Transfer

Bank Draft

Beneficiary Name:

First Last

Bank Account#:

Beneficiary’s Bank Name & Address:

Street Address Parish

Banking Code:

Additional Info:

Credit Bank A/C#:

Name of Bank:

Bank Code:

Signature

Date

Loans

Deposits

Insurance

Other

Loans

Customised deposit solutions with competitive interest rates to help your business thrive

Insurance

Other

Loans

Customised deposit solutions with competitive interest rates to help your business thrive

Insurance

Other

Insurance Products

Estate Planning

Investing

Deposits

Resources