EX-99.6 10 dex996.htm FORM OF NOMINEE HOLDER CERTIFICATION Form of Nominee Holder Certification

Exhibit 99.6

NOMINEE HOLDER CERTIFICATION

NORTHWEST BANCORPORATION, INC.

Up to 1,000,000 Shares of Common Stock Issuable Upon the Exercise of Subscription Rights Distributed to the Holders of Record of Northwest Bancorporation, Inc.

THE TERMS AND CONDITIONS OF THE RIGHTS OFFERING ARE SET FORTH IN THE PROSPECTUS OF NORTHWEST BANCORPORATION, INC. DATED [•], 2010 (THE “PROSPECTUS”).

The undersigned, a broker, custodian bank, or other nominee holder of non-transferable subscription rights to subscribe for and purchase shares of the common stock of Northwest Bancorporation, Inc. (the “Company”) pursuant to the rights offering described and provided for in the Prospectus, hereby certifies to the Company, to Registrar and Transfer Company, as subscription agent for the rights offering, that the undersigned has exercised, on behalf of the beneficial owners thereof (which may include the undersigned), the rights to purchase the number of shares of common stock specified below pursuant to the basic subscription privilege, and on behalf of beneficial owners of rights who have exercised their basic subscription privilege in full, the request to purchase the number of additional shares of common stock specified below pursuant to the over-subscription privilege, the terms of which is described further in the Prospectus, listing separately each exercised basic subscription privilege and any corresponding over-subscription privilege as to each beneficial owner for whom the undersigned is acting hereby:

 

Number of Shares Owned

on Record Date

  

Number of Shares Subscribed For

Under Basic Subscription Privilege

  

Number of Shares Requested Under

Over-Subscription Privilege

     
     
     

 

Print Name of the Nominee Holder:   

 

 

By:  

 

Print Signer’s Name:   

 

 

Contact Name:   

 

Contact Phone Number: