Form 2 Application for Eligibility Certificate by a Corporation (PDF ...
Form 2 Application for Eligibility Certificate by a Corporation (PDF ... Form 2 Application for Eligibility Certificate by a Corporation (PDF ...
Office of Liquor, Gaming and Racing COMPANY PROBITY FORM A. COMPANY DETAILS PART TWO Information to be provided by written answer (i) Full name of company as currently incorporated: ________________________________________________________________ (ii) Other names the company has been known by: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ (iii) Registered office: _________________________________________________ ________________________________________________________________ (iv) Address of principal place of business: ________________________________________________________________ ________________________________________________________________ Number of years at this address: ___________ (v) Postal address: ___________________________________________________ ________________________________________________________________ (vi) Contact Details: Telephones – Business: ( ____ ) __________________ After Hours: ( ____ ) __________________ Mobile: _________________________ Email: _____________________________________ (vii) Preferred contact person: ___________________________________________ (viii) Date of incorporation: _____ / _____ / _____ Signature: ___________________________________ 10
Office of Liquor, Gaming and Racing COMPANY PROBITY FORM (ix) (x) Place of incorporation: _____________________________________________ Australian Company Number (ACN): _________________________________ (or equivalent – please specify). (xi) (xii) Paid Up Capital: $ ________________ Name of the ultimate holding entity of the company: ________________________________________________________________ (xiii) List the following details for each current director, company secretary and any other officeholder (including members of the management board, supervisory board or any other body, by whatever name called) as well as the Chief Executive Officer: Name Position Residential Address Place and Date of Birth (xiv) List the following details for each director and other officeholder who has ceased to hold office during the last five (5) years: Name Last known residential address Date of Cessation Signature: ___________________________________ 11
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Office of Liquor, Gaming and Racing<br />
COMPANY PROBITY FORM<br />
A. COMPANY DETAILS<br />
PART TWO<br />
In<strong>for</strong>mation to be provided <strong>by</strong> written answer<br />
(i)<br />
Full name of company as currently incorporated:<br />
________________________________________________________________<br />
(ii)<br />
Other names the company has been known <strong>by</strong>:<br />
________________________________________________________________<br />
________________________________________________________________<br />
________________________________________________________________<br />
(iii)<br />
Registered office: _________________________________________________<br />
________________________________________________________________<br />
(iv)<br />
Address of principal place of business:<br />
________________________________________________________________<br />
________________________________________________________________<br />
Number of years at this address: ___________<br />
(v)<br />
Postal address: ___________________________________________________<br />
________________________________________________________________<br />
(vi)<br />
Contact Details:<br />
Telephones – Business: ( ____ ) __________________<br />
After Hours: ( ____ ) __________________<br />
Mobile:<br />
_________________________<br />
Email:<br />
_____________________________________<br />
(vii)<br />
Preferred contact person: ___________________________________________<br />
(viii) Date of incorporation: _____ / _____ / _____<br />
Signature: ___________________________________ 10