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DETAILS OF PROPOSED OFFICER AND/OR SHAREHOLDER

Please include full names of the persons ie Greg John SMITH & if the shareholder is a company ie COMPANY PTY LTD A.C.N. 000 000 000

Please include full names of the persons ie Greg John SMITH & if the shareholder is a company ie COMPANY PTY LTD A.C.N. 000 000 000
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Positions Held
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At least 0 shareholdings required.
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Signed Consent

I hereby consent to be named in the ASIC application for registration as a company as:

1. An officer of the company in the capacities indicated above and if a Director, the director has a Directors ID. All directors must comply with the Director ID requirements. Visit http://www.abrs.gov.au/

2. (if indicated above) A shareholder who has agreed to take up the shares listed above and (if the company has elected to have a constitution) who has agreed to the terms of the proposed Shelf Company Services Australia Pty Ltd standard constitution.

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