Quick-Phone: 1300 66 86 09
Quick-Fax: 1300 66 87 09
ONLINE ORDERING
COMPANY DEREGISTRATION ORDER FORM
Name:
Firm:
Phone:
Email:
COMPANY DETAILS
Company Name:
ACN:
REGISTERED OFFICE 
At the office of - c/-
Unit or office
Street number & name
Suburb/City
DIRECTOR DETAILSPlease provide the name of the Company Director who will sign the ASIC form
Family Name
Given Name/s
Residential Address
(not PO Box)

SHAREHOLDER/S DETAILS
NOTE:FULL names of ALL shareholders must be included
Full Name
(include ACN if Company)
Full Name
(include ACN if Company)
Full Name
(include ACN if Company)
Full Name
(include ACN if Company)
Full Name
(include ACN if Company)
COMPULSORY DECLARATION
NOTE: A company cannot apply to be deregistered under subsection 601AA(1) and (2) of the Corporations Act 2001 (Cth) unless:
(a)all members agree to the deregistration;
(b)the company is not carrying on business;
(c)the company’s assets are worth less than $1000.00;
(d)the company has paid all fees and penalties payable under this Act;
(e)the company has no outstanding liabilities; and
(f)the company is not party to any legal proceedings.

Additional Information/Special Requirements

PAYMENT DETAILSPlease debit the following credit card by the amount of $ 143.00 (inc GST)
TYPE OF CARD:
CARD NUMBER: EXPIRY DATE: ()
NAME ON CARD: