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SERIAL NO
CHBKL
CHASE BANK (KENYA) LIMITED
Incorporated in Kenya under the Companies Act (Cap 486) Reg. No. C.45983
APPLICATION FORM
In respect of an issue of Kenya Shillings 10,000,000,000) Subordinated Multicurrency Medium Term Note
Programme of Fixed and Floating Interest Rate Notes due to mature on 1st June, 2022 (the “Notes”) at par
and listing of the Notes on the Fixed Income Securities Market Segment of the Nairobi Securities Exchange.
Offer opens at 9.00 am on the 20th May, 2015 and Offer Closes at 5.00 pm on 4th June, 2015
The Board of Directors shall reject any application in whole or in part if the instructions as set out in the
Information Memorandum and the Application Form are not complied with.
APPLICANT’S STATEMENT
By signing the Application Form overleaf, I /We the applicant (s) herein state that:1. I/We have full legal capacity and having read the Information Memorandum and this Application Form
including the notes at the back I/we hereby irrevocably apply for and request you to accept my/our
application for the under mentioned value of Notes in Chase Bank (Kenya) Limited, or any lesser value of
Notes that may, in your sole and absolute discretion, be allotted to me/us subject to the Articles of
Association of Chase Bank (Kenya) Limited.
2. I/We authorize Chase Bank (Kenya) Limited to enter my/our name in the register of Noteholders of Chase
Bank (Kenya) Limited as holder(s) of Notes to me/us and to issue any refunds due to me/us via Electronic
Funds Transfer in accordance with the terms and conditions in the Information Memorandum.
3. I/We agree that this application shall be irrevocable and shall constitute a contract which shall become
binding upon receipt by Chase Bank (Kenya) Limited, and shall be governed by the terms and conditions
of the notes.
4. I/We acknowledge that Chase Bank (Kenya) Limited reserves the right to reject any application found to
be in contravention of above declarations.
5. I/We confirm that all information provided by me/us on the Application Form is true.
GENERAL INSTRUCTIONS ON COMPLETING THE APPLICATION FORM
6. Applications can only be made through Genghis Capital Limited and NIC Capital Limited.
7. Genghis Capital Limited and NIC Capital Limited will be pleased to assist in understanding the application
process and subsequently filling in the Application Form.
8. Where necessary, applicants are requested to consult their financial advisor. The offer closes 4th June, 2015.
9. Use original Application Form only. Photocopies will not be accepted.
10. Use capital letters with only black/blue biro/ink, within the grid spaces provided. Alterations (other than
deletion of alternatives) must be authenticated by the full signature of the applicant or preferably a new
form used.
11. No individual or organization can make any promises contrary to the allocation criteria specified in the
Information Memorandum
12. Offer account details: Account Name: Chase Bank MTN Programme Tranche 1; Account No: 000200320005;
Bank Code: 30; Swift Code: CKENKENA; Bank Name: Chase Bank Kenya Ltd; Branch Name: Head Office
SERIAL NO
CHASE BANK(KENYA) LIMITED—MEDIUM TERM NOTE PROGRAMME
NOTE APPLICATION FORM (Not For Sale)
This form is to be used with the Information Memorandum and relevant Pricing Supplement relating to Chase Bank MTN Programme of up to KES 10 Billion. Please read the
Information Memorandum, the relevant Pricing Supplement and the instructions for completion on the reverse of this form.This Form is divided into six parts: A,B,C,D,E & F
PART A: APPLICATION — MANDATORY FOR ALL APPLICANTS
APPLICANT POOL
(tick one)
Retail
Institutional
RESIDENCE
(tick one)
Citizenship
(tick one)
Kenyan
CDA ID
CDS ACCOUNT NUMBER (omit leading zeros)
Resident
East African
Non Resident
Foreigner
CDS CLIENT TYPE
APPLICATION AMOUNT (KES) (Minimum Amount of KES 100,000/ - and additional amounts in multiples of KES 100,000/ -)
FIXED INTEREST RATE NOTES
FLOATING INTEREST RATE NOTES
PART B (i): PRIMARY APPLICANT DETAILS
SURNAME (Last Name)
FIRST NAME and Other Names
ID/PASSPORT/ALIEN ID NUMBER
COUNTRY OF ISSUE
PART B (ii): JOINT APPLICANT DETAILS
SURNAME (Last Name)
FIRST NAME and Other Names
ID/PASSPORT/ALIEN ID NUMBER
COUNTRY OF ISSUE
PART B (iii): CORPORATE/INSTITUTION (Name as per certificate of incorporation or registration)
REGISTRATION/INCORPORATION NUMBER
COUNTRY OF REGISTRATION/INCORPORATION
PART C: ADDRESS AND CONTACT DETAILS — MANDATORY FOR ALL APPLICANTS
P.O. BOX
POST CODE
CITY/TOWN
COUNTRY
STREET
TELEPHONE NO
MOBILE NO
FAX NO
EMAIL ADDRESS
PART D (i) : PAYMENT— MANDATORY FOR ALL APPLICANTS
PAYMENT
Authorized Placing Agent
VIA
Banker’s Cheque (Payee in the name of Chase Bank MTN Programme Tranche 1)
(tick one)
Electronic Funds Transfer (EFT)/Real Time Gross Settlement (RTGS)
Irrevocable Bank Guarantee (IBG) (only for Corporate/Institutional applicants)
Letter of Undertaking (LOU) (only for Corporate/Institutional applicants)
PART D (ii) : REFUND, INTEREST, PRINCIPAL REPAYMENT — MANDATORY FOR ALL APPLICANTS
Payment will only be done via Electronic Funds Transfer( EFT)
BANK NAME
BRANCH NAME
ACCOUNT NUMBER
BANK CODE
SWIFT CODE
PART E : SIGNATURES
Signature 1
Signature 2
DATE (DD/MM/YY)
PART F (for official use only) : AUTHORISED PLACING AGENT (APA)
APA Stamp, Code, Date
VIA
Company Seal/Stamp
NOTES TO THE CHASE BANK (KENYA) MTN APPLICATION FORM
Part A
• Tick the appropriate applicant pool, residence, citizenship.
• Complete your CDS account details in the spaces provided.
• Indicate the application amount in Kenya Shillings that you wish to apply for. The minimum investment
amount is KES 100,000/- and additional amounts in multiples of KES 100,000/-.
Part B
• Please note that this Issue will be a fully dematerialized issue. That is, there will be no certificates issued.
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Applicants who do not have a CDS account should arrange to open one at any authorized CDA on or
before the Offer Closure date.
Trusts that have not been incorporated, a partnership or a deceased estate cannot be used. Trustees of
unincorporated trusts, individual partners or executors may apply in their own name (s).
Individual applicants should fill in names as per their CDS accounts in the spaces provided in part B (i).
Joint applicants should fill in their names as per their CDS accounts in the spaces provided in part B (i) for
first applicant and part B (ii) for second applicant.
Corporates/institutional investors should fill in their names as per their CDS accounts in the spaces provided
in part B (iii).
Part C
• All applicants are required to fill in their address and contact details in the spaces provided.
Part D
• Please tick the appropriate payment option in Part D (i) for the application amount indicated in Part A.
• Payments for all application amounts should be made in Kenya Shillings (KES) to the receiving bank on or
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before Offer Closure date.
Corporate and/or Institutional Investors may opt to pay via an Irrevocable Bank Guarantee (IBG) or Letter of
Undertaking (LOU). Should this be the preferred option, please ensure that a copy of the IBG or LOU is
attached to this application form to be received on or before Offer Closure date.
For application amounts of KES 1,000,000/- and above should be paid to the receiving bank via EFT/RTGS
to the receiving bank account as follows: Account Name: Chase Bank MTN Programme Tranche 1; Account
No: 000200320005; Bank Code: 30; Swift Code: CKENKENA; Bank Name: Chase Bank Kenya Ltd; Branch
Name: Head Office
All refunds will be paid to Noteholders by the receiving bank via Electronic Funds Transfer (EFT) to the
Noteholders bank account details indicated in part D (ii).
All interest and principal payments will be paid to the Noteholder(s) via Electronic Funds Transfer (EFT) to the
Noteholders bank account details indicated in part D (ii).
Part E
• All applicants are required to append their signatures in part E of this as part of their acceptance.
• Copies of identification/passport/alien ID should be attached to this Note Application form in the case of
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individual and/or joint applicants and copies of their certificates of incorporation or registration in the case
of corporate/institutional applicants.
Corporate/Institutional applications must be signed by authorized signatories and the company seal/stamp
appended in the space provided. Applicants signing by thumbprint must have the thumbprint witnessed
next to it and the witness should provide his/her full names and identification within the signature box.
Part F
• This section is reserved for the official use of the Placing Agents. The appointed Placing Agents for this issue
are Genghis Capital Limited and NIC Capital Limited.
Important Note: Any application forms received by Genghis Capital Limited and NIC Capital Limited after Offer
Closure date will automatically be rejected.