Statement Confirming that
the Applicant has No Ties to Anti-Social Forces
Date of Submission:
DD / MM / YYYY
To President and CEO,
Tokyo Stock Exchange, Inc.
Name of Company:
Name (Signature) and Title of Representative:
To the best of the Company's knowledge, neither the corporate group of the Company, its officers as
well as persons equivalent thereto, major shareholders, or main clients (hereinafter referred to as "the
corporate group and/or its related parties") is an anti-social group; that no anti-social forces are involved
in the operation of the corporate group of the Company; that neither the corporate group nor its related
parties have provided funds or conducted any other acts such as the maintenance of, cooperation or
involvement in the operation of anti-social forces; and that neither the corporate group nor its related
parties intend to have contact with anti-social forces.
Therefore, the Company hereby confirms that, to the best of our knowledge, neither the corporate
group nor its related parties have any relationship with any anti-social forces.
Moreover, if the Company obtains new information regarding the relationship of the corporate group
and/or its related parties with anti-social forces through media reports or other means, we will
immediately report such fact and its contents to Tokyo Stock Exchange (TSE), and will promptly strive
to obtain information to confirm the facts, and report the actual situation to TSE.
If any significant breach is proved to have taken place with respect to the above, we will raise no
objection to any measure taken by TSE.
(Notes)
(a) This document must be submitted by each issuer that applies for an initial listing.
(b) When the same issuer simultaneously files initial listing applications for multiple foreign ETN trust
beneficiary certificates, the submission of one Statement will suffice.
(c) If an issuer has already filed a Statement to TSE, there will be no need to submit another Statement.