The Asia Gold Mining Asset Corporation (AGMAC)

Skyper Villa,
Taunusanlage 1,
60329 Frankfurt am Main,
Germany.

AGMAC Shareholder Declaration Form - 118A/5/13

I, Mister/Miss* FREDDY FITRIADY, a holder of Indonesia Passport/National Identification Card* Number 1371100909780003,
date of expiry on ____________ (if applicable) hereby declare that I am the sole beneficiary of all AGMAC shares and options
as stated in my online shareholder account number 100000320968.
I also declare that, my permanent address is:
Address:
Address:
City:
Zip/Post Code:
Country:
I can be reached at:
Mobile Number:
Land Line Phone Number:
Fax Number:
Email Address:
I prefer to be reached by:

Email

Mobile Phone

The best time to reach me is between: ______ and _______ (local time)
I declare that all the information provided above is true to my knowledge, and that I will be held accountable should I purposely
provide false information.

--------------------------------------Signature
FREDDY FITRIADY
Date: ____ Day _____ Month _____ Year

* Cross out whichever is not applicable

* Fill up in BLOCK LETTERS only