Form 2 Application for Eligibility Certificate by a Corporation (PDF ...

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