QUICK COMPANY ORDER FORM

Quick-Phone: 1300 66 86 09
Quick-Fax: 1300 66 87 09
ONLINE ORDERING

PROPOSED COMPANY DETAILS

QUICK COMPANY ORDER FORM
Name:
Firm:
Phone:
Email:

Preferred Company Name:

Is this a Registered Business Name?:

YesNo If Yes, in which State/s or Territory/s is it registered?

Which State or Territory of Incorp.:

Type of Company:

Standard Pty LtdUnlisted Public (Ltd)NLLimited by Guarantee
Other Type (i.e. Professional Practice) please indicate profession or type of company required below:

Is the Company a sole purpose superannuation trustee company or "Special Purpose" company YesNo

Registered Office Address:

Occupier of Registered Office:

(only required where Reg. Off. is different to business address i.e. care of accountants or solicitors)

Principal Place of Business:

Identify Ultimate Holding Company:
(if applicable)
ACN or ARBN:

Country of Registration (if not Australia)

COMPANY OFFICERS & SHAREHOLDERS (If shareholder a company please provide ACN or Country of Registration)

1. (To be Chairman)
Family Name	Given Name/s
Full Street Address
Date of Birth	Place of Birth (Town/State/Country)
Number of Shares	Class ORD or Paid: $1/share OR: $
Beneficially Held?	YesNo - If shares are held on behalf of another person, Trust or Super Fund provide details below:
Details of Beneficial Owner:
Position/s Held	DIRECTOR SECRETARYPUBLIC OFFICER

2.
Family Name	Given Name/s
Full Street Address
Date of Birth	Place of Birth (Town/State/Country)
Number of Shares	Class ORD or Paid: $1/share OR: $
Beneficially Held?	YesNo - If shares are held on behalf of another person, Trust or Super Fund provide details below:
Details of Beneficial Owner:
Position/s Held	DIRECTORSECRETARYPUBLIC OFFICER

3.
Family Name	Given Name/s
Full Street Address
Date of Birth	Place of Birth (Town/State/Country)
Number of Shares	Class ORD or Paid: $1/share OR: $
Beneficially Held?	YesNo - If shares are held on behalf of another person, Trust or Super Fund provide details below:
Details of Beneficial Owner:
Position/s Held	DIRECTORSECRETARYPUBLIC OFFICER

4.
Family Name	Given Name/s
Full Street Address
Date of Birth	Place of Birth (Town/State/Country)
Number of Shares	Class ORD or Paid: $1/share OR: $
Beneficially Held?	YesNo - If shares are held on behalf of another person, Trust or Super Fund provide details below:
Details of Beneficial Owner:
Position/s Held	DIRECTORSECRETARYPUBLIC OFFICER

5.
Family Name	Given Name/s
Full Street Address
Date of Birth	Place of Birth (Town/State/Country)
Number of Shares	Class ORD or Paid: $1/share OR: $
Beneficially Held?	YesNo - If shares are held on behalf of another person, Trust or Super Fund provide details below:
Details of Beneficial Owner:
Position/s Held	DIRECTORSECRETARYPUBLIC OFFICER

6.
Family Name	Given Name/s
Full Street Address
Date of Birth	Place of Birth (Town/State/Country)
Number of Shares	Class ORD or Paid: $1/share OR: $
Beneficially Held?	YesNo - If shares are held on behalf of another person, Trust or Super Fund provide details below:
Details of Beneficial Owner:
Position/s Held	DIRECTORSECRETARYPUBLIC OFFICER

SPECIAL STATIONARY REQUESTS	All companies come fully bound in a 3D ring binder and are delivered overnight
IF A BINDER IS NOT REQUIRED - TICK HERE

ELECTRONIC COPY	Please provide a copy of this record on disk ON DISK EMAIL

SPECIAL REQUIREMENTS ?	simply provide details in the box provided below or call 1300 66 86 09

DECLARATION	I declare that I hold the necessary consents of all the party/s listed on this order form.
	I declare the above statement to be true. Dated
PAYMENT DETAILS	Please debit the following credit card by the amount of $ 675.00

TYPE OF CARD:	Visa Mastercard Diners Club Amex Bankcard
CARD NUMBER:	EXPIRY DATE: ()
NAME ON CARD:
I the person sending this order hereby state that I hold a signed copy of this payment authorisation should a copy be required by Quick Companies Pty. Ltd.

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