EX-99.2 4 ex992.htm DRIP ENROLLMENT FORM ex992.htm
EXHIBIT 99.2
 
Harleysville National Corporation
Dividend Reinvestment and Stock Purchase Plan
Enrollment Form
 
 
HARLEYSVILLE NATIONAL CORPORATION
 
DIVIDEND REINVESTMENT AND STOCK PURCHASE PLAN
 
ENROLLMENT FORM
 
ENROLLMENT IN THE PLAN
 
I wish to enroll in Harleysville's Dividend Reinvestment and Stock Purchase Plan and name American Stock Transfer & Trust Company LLC as administrator as described in the plan prospectus. I authorize the administrator to take the following action:
 
ACCOUNT NAME AND ADDRESS
 
ACCOUNT NUMBER
     
     
     
     
     
Social Security/Tax I.D. Number
 
PRINT - Name of Account Owner
     
   
Signature of Account Owner
     
Social Security/Tax I.D. Number
 
PRINT - Name of Account Owner
     
     
   
Signature of Account Owner
 
 

 
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  Mailing Address                                                                                     Apt. No.
 

                                                             
City                                State                                Zip           Daytime Phone Number
 
 
DIVIDEND PAYMENT AND REINVESTMENT PARTICIPATION (Please check ONE box.)
 
 
Check the participation option in which you wish to enroll. Under either option, a plan participant may make cash investments in any amount ranging from a minimum of $100 per payment to $100,000 per quarter as defined in the prospectus.
 
(   ) FULL REINVESTMENT
(   ) PARTIAL REINVESTMENT
All dividends reinvested.
Invest the dividend on ________* of my shares and pay balance in cash. Dividends will be reinvested on ALL shares enrolled in the plan. (*Indicate number of shares to be subject to the plan.)
   
(    ) CASH ONLY PAYMENT
(   ) VOLUNTARY (OPTIONAL) CASH
All dividends are paid in cash.
PAYMENT All dividends are paid in cash for shares you presently hold. Dividends paid on  future shares purchased with voluntary cash payments will be reinvested
 
If no participation option is selected, the administrator will assume you desire FULL reinvestment of your dividends.
 
Please use the following addresses and telephone number to contact the Administrator:
For Inquiries:  American Stock Transfer & Trust Company LLC
For transactions:  American Stock Transfer and Trust Company LLC
             Attention: Shareholder Relations Dept
Attn:  Plan Administration Dept.
6201 15th Avenue
P.O. Box 922 Wall Street Station
Brooklyn, NY  11219
New York, NY  10269-0560
Phone Toll Free 1- 877-534-8323
 
 

 
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