(Use separate form for each company/complaint)
(Please tick (? ) the appropriate item and complete all columns in capital letters)

Securities & Exchange Commission
Case Ref. No.
File No.
(Complaint Desk) Ref. No.      
Jiban Bima Tower (15th & 16th Floor) Date      
10, Dilkusha C/A         

Dear Sirs

Please take up the matter with the company for immediate redressal of my complaint  particulars of which are as under: 

A. Name & Address with phone No. of the Investor: 

B. Folio No: 

C. Name & Address of the Company complained against:

D. Name of the Registrar/Transfer Agent (if any)   : 

E. SEC acknowledgement Reference No.   : 
(In case of reminder)

F. Nature of complaint     :
Type / Category:

(i) Issue/ Offer -------------------- non-receipt of :
(a) Refund Warrant/ Allotment Advice 
(b)  Revalidation  of Refund Warrant (RW) 
(c )  Duplicate RW for  correct amount 
(d)  Duplicate RW after Indemnity (against lost RW) 
(e)  Duplicate RW on correct bank (give details)
(f) Short Refund
(g) Others (specify)
(ii) Dividend-----------------------non receipt of 
(a)  Final    ( at                            % of the FY 
(b) Interim  (at                             % of the FY )
(iii) Shares ----------------------- non receipt of certificates in/after:
(a) Allotment letter/Exchange of AL 
(b) Conversion 
(c ) Splitting 
(d) Transfer 
(e)  Endorsement
(f)  Bonus (at             % of the FY )
(g) Transmission 
(h) Consolidation
(i)  Duplicate on submission of Indemnity Bond 
(iv) Debenture/Bond -------------------------- non-receipt of:
(a) Interest 
(c) Consolidation certificate 
(d) Conversion certificate 
(e) Redemption Amount
(f) Transmission
(g) Splitting certificate 
(h) Delay in payment of interest/ redemption amount
(i) Exchange of allotment letter 
(j) Endorsement
(k) Duplicate on submission of indemnity bond
(v) Miscellaneous --------------------------------- non-receipt of:
(a)  Annual Report 
(b) Interest on delayed refund payment 
(c) Brokerage/Commission payment 
(d) Offer for Rights
(e) Registration of change in address
(f) Half yearly account
(g) Any other (specify)
G. Particulars of the application/security held
(a) No. of security applied for/held 

(b) Kind of security      : 

(i) Share 
(ii) Debenture 
(iii) Others 
(c) Mode of payment (details)    :
(i) Cash 
(ii) Cheque/ D. D/P.O : No. ___ Dated ______Amount Tk._____: Drawn on ________
(d) Application deposited at  :

(e) Bank serial No. :

(f) Photocopy of Bank Certificate enclosed 

(i) Yes   (ii) No
(g) Photocopy of acknowledgement slip enclosed  : 
(i) Yes   (ii) No
(h) Original Refund Warrant No.     : 
(in case of revalidation/duplicate)

(i) Period on/for which dividend/interest/ maturity amount/redemption amount due

(j) Date on which security was forwarded to the Company/Registrar/Transfer Agent 

(k) Indemnity Bond sent for issue of duplicate   : 

(I) Yes, Date:______________  (ii) No.
H.  Other details, if any, in brief

I. Dates of earlier correspondence with the Company/ Registrar/Transfer Agent

J.  Enclosure, if any (specify) 

Place                                           Date                                                           Signature of the security holder

NOTE: It would be advisable to address the complaint to SEC only if the Company / Registrar/Transfer Agent has not responded inspite of having sent two reminders over a period of at least one month.

Securities and Exchange Commission

Received the complaint reference No.___________________ dated______________________ for examination and necessary action (if applicable). 

Official seal                                                                                                           Signature & date

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