+
+
Joint Owner (if any), Minor’s Name or Trustee(s) Name
Name, Custodian Name or Full Trust Name
Single/Joint Account
Custodial Account
Trust Account
You must provide BNY Mellon with the following three pages from
the Trust Document: 1. Title Page 2. Powers Page and
3. Signature Page
Account Legal Registration (Choose One)
Account Information
Street Number Street Name Apt./Unit Number
Use a black pen. Print in
CAPITAL letters inside the grey
areas as shown in this example.
ABC
123
X
Joint - Will be presumed to be joint tenants with rights of survivorship unless
restricted by applicable state law or otherwise indicated.
Custodial - A minor is the beneficial owner of the account with an adult custodian managing
the account until the minor comes of age, as specified in the Uniform
Gift/Transfer to Minors Act in the minor’s state of residence. Please note that
both the minor’s and custodian social security number must be provided.
Trust - Account is established in accordance with the provisions of a trust agreement.
USA
Other
You must complete a W-8BEN form.
Please call the phone number above to
obtain a form.
Citizenship
Date of Trust (mm/dd/yyyy)
Date of Birth (Primary Account Holder/Minor) Date of Birth (Joint Account Holder/Custodian)
City/Town State/Province Postal Code Country
Minor’s State (if applicable)
Social Security Number (SSN) (Primary Account Holder/Minor) or
Employer Identification Number (EIN)
Social Security Number (SSN) (Joint Account Holder/Custodian)
E62UEF
00GBMB-BNY-WEB
.
BNY Mellon
PO Box 30170
College Station, TX 77842-3170
Within USA, US territories & Canada 866 259 2285
Outside USA, US territories & Canada 201 680 6578
www.mybnymdr.com
Direct Stock Purchase Plan - Initial Enrollment Form
Alon Holdings - Blue Square Israel Limited
BSIB
Name
Address
City, State, Zip
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+
E64UEF
.
00GP9D-BNY-WEB (Rev. 7/12)
BNY Mellon
PO Box 30170 College Station, TX 77842-3170
Please return completed form to:
Partial Share Amount
Home Telephone Number Business Telephone Number
Check one box only. If you do not check any box, then FULL DIVIDEND REINVESTMENT will be assumed. If the plan permits, you may make optional cash investments at any time under each of the participation options below.
Full Dividend Reinvestment
Please mark this box if you wish to reinvest all dividends that become payable on this account, on all stock now held
or any future holdings, including shares purchased with optional cash investments.
All Dividends Paid in Cash (No Dividend Reinvestment)
Please mark this box if you wish to receive dividend payments in cash on all stock now held or any future holdings,
including shares purchased with optional cash investments.
Partial Dividends Paid in Cash
Please mark this box and specify the number of whole shares on which you wish to receive dividend payments in cash.
The dividends on all remaining shares or any future holdings, including shares purchased with optional cash
investments, will be reinvested.
At BNY Mellon, we take privacy seriously. In the course of providing services to you in connection with employee stock purchase plans, dividend reinvestment plans, direct stock purchase plans, direct registration services and/or custody services, we
receive nonpublic, personal information about you. We receive this information through transactions we perform for you, from enrollment forms, automatic debit forms, and through other communications with you in writing, electronically, and by telephone.
We may also receive information about you by virtue of your transaction with affiliates of BNY Mellon or other parties. This information may include your name, address (residential and mailing), social security number, bank account information, stock
ownership information, date of birth, government-issued identification number, and other financial information.
With respect both to current and former customers, BNY Mellon does not share nonpublic personal information with any non-affiliated third-party except as necessary to process a transaction, service your account or as required or permitted by law. Our
affiliates and outside service providers with whom we share information are legally bound not to disclose the information in any manner, unless required or permitted by law or other governmental process. We strive to restrict access to your personal
information to those employees who need to know the information to provide our services to you. BNY Mellon maintains physical, electronic and procedural safeguards to protect your personal information.
BNY Mellon realizes that you entrust us with confidential personal and financial information and we take that trust very seriously.
Privacy Notice
Please refer to the plan prospectus or brochure before enrolling.
Signature 1 - Please keep signature within the box.
Signature 2 - Please keep signature within the box.
Date (mm/dd/yyyy)
To be valid, this form must be signed by all account holders.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number, and 2. I am not subject to backup withholding because (a) I am exempt
from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding, or (c) the IRS has notified me that I am no longer subject to
backup withholding, and 3. I am a U.S. person (including a U.S. resident alien).
Certification Instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest
and dividends on your tax return.
Enrollment forms will be processed within 5 business days of receipt. Confirmation of enrollment will not be mailed; however, a transaction statement will be mailed once there is activity in your
account. If you would like to confirm your enrollment in the plan, please call us at the number referenced on the front page.
Make checks payable to BNY Mellon. Please refer to the plan prospectus or brochure for the minimum/maximum amount of the initial investment. No interest will be paid on the
funds held pending investment.
By participating in the plan, I agree to be bound by the terms and conditions of the prospectus or brochure that governs the plan. I have read and fully understand the terms and conditions of
the prospectus or brochure. I further agree that my participation in the plan will continue until I notify BNY Mellon in writing that I desire to terminate my participation in the plan. Upon providing
such notification, I acknowledge that my withdrawal from the plan will be subject to the terms and conditions of the prospectus or brochure that governs the plan. By signing this form, I am
certifying that I am of legal age in the state or country of my residence.
Please enclose a check for your initial investment, plus a $10.00 enrollment fee.
+
+
E5UEMD
.
Use a black pen. Print in
CAPITAL letters inside the grey
areas as shown in this example.
ABC
123
X
Name
Address
City, State, Zip
Holder Account Number
__ __ __ __ __ __ __ __ __ __ __
Direct Stock Purchase Plan - Direct Debit Authorization - Monthly
Funds will be withdrawn on the 25th
day of each month or on the
preceding business day.
This plan allows for a minimum amount of $50 with a maximum of $100,000
per Year. If applicable, an enrollment fee will be deducted from the initial
investment.
This form is to be used for recurring debits only.
Do not use for one time purchases.
Daytime Telephone Number
Name(s) in which the above account is held
Financial institution account number Financial institution routing number
Note: DO NOT USE A CREDIT CARD. If you do not know your account number or the routing number, please see the reverse side of this form or check with your financial institution.
Account numbers must be in numeric format.
+
Signature 1 - Please keep signature within the box.
Signature 2 - Please keep signature within the box.
Date (mm/dd/yyyy)
Dollar Amount:
Checking
Account
Savings
Account
Individual Joint
Financial Institution Information
Other
B.
Please select one.
A.
Please select one.
00H3PC-BNY-WEB
$
,.
Note: If you are not currently enrolled in this company’s Plan, by signing this form, you agree to the following: (1) to enroll in the Plan for full dividend reinvestment so that all of your dividends will be used to
purchase additional shares (if available); (2) to be bound by the terms and conditions of the prospectus or brochure that governs the Plan; (3) that you have read and fully understand the terms and conditions
of the prospectus or brochure; and (4) that you further agree that your participation in the Plan will continue until you notify BNY Mellon in writing or by other available means that you desire to terminate
participation in the Plan. Upon providing such notification, you acknowledge that withdrawal from the Plan will be subject to the terms and conditions of the prospectus or brochure that governs the Plan.
I/We hereby authorize BNY Mellon to make monthly automatic transfers of funds from the above account in the amount shown. This deduction will be used to purchase shares to be deposited into my/our account.
All owners of the financial institution account must sign below.
Please return completed form to:
BNY Mellon
PO BOX 30170
College Station, TX 77842-3170
BNY Mellon
PO Box 30170
College Station, TX 77842-3170
Within USA, US territories & Canada 866 259 2285
Outside USA, US territories & Canada 201 680 6578
www.mybnymdr.com
Alon Holdings - Blue Square Israel Limited
BSIB
How to complete this form
..
1. This company plan offers only monthly deductions. Check the box to confirm your agreement.
2. Amount of automatic deduction: Indicate the amount authorized to transfer from your account to purchase additional shares.
3. Indicate the type of account held with the financial institution.
4. Indicate checking or savings.
5. Print the complete financial institution account number.
6. Print the financial institution routing number from your check or savings deposit slip. If you are using a savings account, contact your
financial institution for the routing number.
7. Print the name(s) in which the financial institution account is held.
8. All authorized owners of the financial institution account must sign this form.
6UEMD_00H3QA-WEB (Rev. 7/12)
John A. Doe
Mary B. Doe
123 Your Street
Anywhere , U.S.A. 12345
PAY TO THE
ORDER OF
Bank of Anywhere
123 Main Street
Anywhere, USA 12345
FOR
SAMPLE (NON-NEGOTIABLE)
20
63-858
670
$
Name(s) in which
account is held
Financial institution and
branch information
123456789 12345678901234567 1234
Bank Account Number
Check Number
Bank Routing Number
This number typically begins with a 0, 1, 2 or 3.
SAMPLE CHECK
