R OMPETROL DOWNSTREAM SA STR MACUL ROSU NR 13

FORMULAR PENTRU DEBLOCARE CARDURI

R R OMPETROL DOWNSTREAM SA STR MACUL ROSU NR 13 ompetrol Downstream S.A.

str. Macul Rosu nr. 1-3, sector 1

010992, Bucuresti, Romania

T + 40 21 206 75 00

F + 40 21 206 75 80

www.fillandgo.ro

FORM FOR UNBLOCKING THE CARDS

Company’s Name:

Current Number	Vehicle registration number	Card number
1		8	0	1	2	0	1
2		8	0	1	2	0	1
3		8	0	1	2	0	1
4		8	0	1	2	0	1
5		8	0	1	2	0	1

- The form should be transmitted signed and stamped to the following fax number: XXXXXXX or email

Name of the contact	Authorized Signature	Date	Stamp

Nr. Registrul Comertului:

J40/1716/2000

CUI 12751583 (R)

RO37RNCB5010000205290032

BCR sector 1

Capital social:

20,454,470.40 Lei