I, [full name of representative / shareholder], the undersigned, declare that the original share certificate No. x, issued in the name of [shareholder] in respect of xx ordinary shares in [CompanyName], has been lost, mislaid or destroyed.
On behalf of [shareholder], I request that a replacement certificate be issued in its place.
In consideration, I undertake to indemnify and hold harmless the company, directors, officers, company secretary and shareholders from all losses, costs, damages and expenses in connection with issuing a replacement certificate.
SIGNED AT [PLACE] ON [DATE]
________________________________________
[full name of representative / shareholder] for [shareholder]
