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20230712_ITIC_Pemanggilan RUPS_31340808_lamp4.pdf
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Surat Kuasa
Menghadiri Rapat Umum Pemegang Saham Luar Biasa
PT Indonesian Tobacco Tbk.
Power Of Attorney To Attend Extraordinary General Meeting Of Shareholders
PT Indonesian Tobacco Tbk.
Yang bertanda tangan di bawah ini:
The undersigned
Nama : .................................................................................................
Name
Jabatan : .................................................................................................
Position
*(untuk diisi jika mewakili badan hukum/ to be filled if Authorizer represents a legal entity)
Alamat : .................................................................................................
Address
Nomor KTP/ Paspor : .................................................................................................
ID Card/ Passport No
Alamat E-mail : .................................................................................................
E-mail Address
Nomor Telepon : .................................................................................................
Phone Number
Dalam hal ini sebagai Pemegang Saham dan pemilik sah atas ........................................ saham yang terdaftar
dalam daftar pemegang saham PT Indonesian Tobacco Tbk. pada tanggal 11 Juli 2023, yang selanjutnya disebut
sebagai Pemberi Kuasa;
In this matter as a shareholder and the legal owner of the ........................................ that registered in the PT Indonesian
Tobacco Tbk. shareholder register, as of July 11th, 2023 hereinafter referred to as Authorizer.
Dengan ini memberikan kuasa (dengan/tanpa)* hak substitusi kepada: *coret salah satu
Herewith confer a power of attorney (with/without)* substitution right to *scratch one
Nama : .................................................................................................
Name
Alamat : .................................................................................................
Address
Nomor KTP/ Paspor : .................................................................................................
ID Card/ Passport No
Alamat E-mail : .................................................................................................
E-mail Address
(“Penerima Kuasa”/ the “Attorney”)
-----------------------------------------------------------------KHUSUS-----------------------------------------------------------------
SPECIFICALLY
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Untuk menghadiri dan menyampaikan tanggapan, pertanyaan dan memberikan suara dalam Rapat Umum
Pemegang Saham Luar Biasa PT Indonesian Tobacco Tbk. yang selanjutnya disebut (“Rapat”) yang diadakan di
Jakarta pada tanggal 3 Agustus 2023 (atau tanggal lainnya sesuai dengan peraturan yang berlaku) dan
memberikan suara atas mata acara Rapat sebagai berikut:
To attend and to convey response, question and vote in the Extraordinary General Meeting of Shareholder of PT Indonesian
Tobacco Tbk. hereinafter referred to as the (“Meeting”) to be held in Jakarta, August 3rd, 2023 (or other date of replacement
in accordance with the applicable laws and regulation), and to vote with respect to the following agendas:
Mohon Diisi Dengan Tanda (√) sesuai
pilihan
Mata Acara Rapat Please fill with (√) as you choose
No
Meeting Agendas Setuju Tidak Abstain
For Setuju Abstain
Against
1 Perubahan Susunan Anggota Dewan Komisaris Perseroan
Changes in Composition of Members of the Company’s Board of
Commissioners
Penerima Kuasa wajib memberikan suara sebagaimana tersebut di atas sesuai dengan pilihan Pemberi Kuasa
selaku Pemegang Saham, pada setiap mata acara Rapat.
The Attorney is obliged to vote as mentioned above in accordance with the choice of the Authorizer as the Shareholder, at
each Meeting Agenda.
Pemberi Kuasa dengan ini menyatakan bahwa suara dalam setiap mata acara Rapat yang disampaikan
berdasarkan Surat Kuasa ini adalah sah dan benar dan surat kuasa ini dapat digunakan sebagai bukti bilamana
diperlukan.
The Authorizer hereby confirm that the votes in the each agenda of the Meeting casted based on this Power of Attorney are
valid and true and this Power of Attorney can be used as evidence if necessary.
Demikian Surat Kuasa ini dibuat agar dipergunakan sebagaimana mestinya.
Thus this Power of Attorney was made to be used as it should.
Pemberi Kuasa Penerima Kuasa
The Authorizer The Attorney
Materai Rp
10.000,-
Stamp Duty
____________________ ____________________
Nama/ Name Nama/ Name
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