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STATEMENT OF CHANGE IN CERTAIN PARTICULARS

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					                                                                     Business Names Act Form 4
      ABN: 29 597 409 596                                     This form is effective from 1 July 2005


 STATEMENT OF CHANGE IN CERTAIN                                                                                                BN


         PARTICULARS
                                 Instructions
     Date Received               Please complete and sign all relevant sections.
                                 It is an offence to make false statements on this form.
                                 Send to GPO Box 3111 Brisbane Qld 4001 or your local Office of Fair Trading or fax it to
                                 (07) 3119 0249. Call 13 13 04 or see www.fairtrading.qld.gov.au for local office details.
                                 Please Note
                                 Complete Business Names Act Form 5 if the business name is no longer required.
FEES: There is no lodgement
                                 You must fill out this form for:
fee on this form. However a      1. Changes in business details including changes to the:
late lodgement fee is payable      • postal address or address of principal place of the business or other place/s
on any other changes that            where business is carried on under the business name;
have occurred MORE THAN            • residential address of any individual carrying on business under the
ONE MONTH prior to the
date the form is lodged,             business name;
except for changes in postal       • registered office or address of a corporation (other than a corporation
address, residential address         registered under the Corporations Act) carrying on business under the
and nature of business.              business name; and/or
No GST Payable                     • nature of the business.
Fees may be altered at any       2. Changes in proprietorship (owners) including if new persons (individuals or
time by regulation.              corporations) are commencing business under a registered business name and/or
PAYMENT: An invoice will be      persons (individuals or corporations) are ceasing business but business
issued if necessary. A receipt   is continuing under the business name.
will not be issued unless        3. Changes in the name of any individual carrying on business under the business
specifically requested.
                                 name (eg. by marriage or legal process) or the name of a corporation other than a
                                 corporation registered under the Corporations Act as ASIC advises Fair Trading
                                 of these changes.
                                 Warning
                                 You and / or your partners must sign and date this form in Part 4.
                                 Proof of ID – Individuals applying for proprietorship of a registered business name
                                 must provide proof of identification with the application (refer to Part 2, section 5).
                                 Privacy Statement
                                 The Department is collecting information, including personal information, on
                                 this form as required by the Business Names Act 1962. The Department usually
                                 passes some of this information on to other State or Commonwealth agencies
                                 when requested. In accordance with the Act, the Business Names Register, which
                                 comprises computer-searchable electronic data and paper documents lodged, is
                                 available for inspection by the public upon payment of a prescribed fee. Any credit
                                 card payment details will be separated from the form and securely stored.


1. Lodging party                 Name ................................................................................................................................
name and address
This section must be
                                 Address .............................................................................................................................
completed.
                                 Suburb ...................................................        State                         Postcode

                                 Phone (             ) ........................................    Fax (            ) .................................................



2. Business Details              Business Name ................................................................................................................

                                 Registration No. BN ..........................................................................................................


                                 Business Names Act 1962 • Section 12 (1) (a), 2 3 & 4 • Form 4 V.10 2005                                                 Page 1 of 4
Part 1 – Changes in Business Details
1. Change of Postal                   New Address ....................................................................................................................
Address        (No late fee)
Insert post office box or, office,      Suburb ...................................................           State                          Postcode
floor, building name, street
number & name, suburb/city.           Date of change                       /            /


2. Change of                          Shop / Office no. ............... Floor ...................Building name ..............................................
Principal Place of
Business                              Street no. and name ..........................................................................................................
Note – This must be a Qld
address. Post Office Box address
                                      Suburb ..........................................................State                               Postcode
not accepted.
                                      Email..................................................................................................................................
This change requires at least one
proprietor to sign. Refer to Part 4                                        /            /
- Signatures.                         Date of change


3. Change in Other                    Ceased Address ................................................................................................................
Places of Business
Insert office, floor, building
                                      Suburb ...................................................           State                          Postcode
name, street number & name,
suburb/city.                          Date ceased                      /           /
Post office box address not
accepted.
                                      New Address ....................................................................................................................
This change requires at least one
proprietor to sign. Refer to Part 4   Suburb ...................................................           State                          Postcode
- Signatures.
                                      Date commenced                           /            /


4. Change in
Proprietor’s Residential              Name ................................................................................................................................
Address (No late fee)
                                      New Address .....................................................................................................................
Insert floor, building name, street
number & name, suburb/city.
Post Office box not accepted.          Suburb ...................................................           State                          Postcode
This does not apply to change                                              /            /
of registered office of a company
                                      Date of change
or residential address of company
directors.


5. Change in Nature of
Business        (No late fee)
                                      New Nature of Business ...................................................................................................
Insert a concise description of       ...........................................................................................................................................
the nature of business.


6. Change in                          Name of Corporation .........................................................................................................
Registered Office
for Corporation Not                   New Address ....................................................................................................................
Registered under the
Corporations Act                      Suburb ...................................................           State                          Postcode
Insert office, floor, building name,
street number & name, suburb/city.    Date of change                       /            /
This change requires at least one
proprietor to sign. Refer to Part 4
- Signatures.




                                      Business Names Act 1962 • Section 12 (1) (a), 2 3 & 4 • Form 4 V.10 2005                                                      Page 2 of 4
Part 2 – Changes in Proprietorship
1. Ceasing to Carry
on Business                             (i)     Name ................................................................................................................................
This section must be completed by               Date ceased                /            /
the proprietor(s) ceasing business
under this business name.               (ii)    Name ................................................................................................................................
(If current proprietor(s) are
ceasing and no other person(s)                  Date ceased                /            /
are commencing, use Form 5)
Insert full name of each individual     (iii)   Name ................................................................................................................................
/ corporation ceasing to carry on
business under this business                    Date ceased                /            /
name and the date of cessation.


2. Continuing to                         (i)    Full name ..........................................................................................................................
Carry on Business
Insert full name of each individual /
corporation continuing to carry on
                                         (ii)   Full name ..........................................................................................................................
business under this business name.


3. Individuals                           (i)    Name ................................................................................................................................
Commencing to
Carry on Business                               Date commenced                         /           /
Insert full name (initials will
not be accepted), residential                   Address .............................................................................................................................
address, date and place of
birth and the date on which                     Suburb ...................................................        State                         Postcode
each individual commenced to
carry on business under this                    Place of Birth ....................................................................................................................
business name.                                                                                                    (town, state and country)

                                                Date of birth                  /           /
Proof of ID must
be submitted.                           (ii)    Name ................................................................................................................................
(See section 5 below).
                                                Date commenced                         /           /

                                                Address .............................................................................................................................

                                                Suburb ...................................................        State                         Postcode

                                                Place of Birth ....................................................................................................................
                                                                                                                  (town, state and country)

                                                Date of birth                  /           /


4. Corporations                                 Corporation / Company Name ..........................................................................................
Commencing to
Carry on Business                               Address of reg’d office .......................................................................................................
Insert full name, details of the
registered office, Australian                    Suburb ...................................................        State                         Postcode
Company Number (A.C.N.)
and the date on which each                      Date commenced                         /           /
corporation commenced to carry
on business under this business
name. If no A.C.N., please advise               A.C.N. / ARBN (Not ABN) .................................................................................................
the title of the Act under which the
corporation is incorporated.


5. Proof of ID                                  If you’re an individual commencing to carry on business you must provide proof of
Certified copies (by a Commissioner              identification with this application. ID must be in the form of one of the following:
of Declarations, Justice of the
Peace or a lawyer) are acceptable                    •    a current Passport; or
for all proof of ID documents.                       •    an Australian citizen certificate; or
Original documents should not be
                                                     •    a current Australian or New Zealand driver’s licence; or
submitted through the mail. If the
applicant attends in person OFT                      •    a current Australian tertiary student identity card (including photo and signature); or
may take a copy of an original.                      •    a current Commonwealth or State public service identity card; or
However, if there are multiple
applicants and only one applicant                    •    a current Australian pension concession card; or
attends in person, the applicant                     •    a current card 18+; or
must have certified copies of other
applicants’ proof of identification.                  •    a birth certificate or extract from a birth entry.

                                                Business Names Act 1962 • Section 12 (1) (a), 2 3 & 4 • Form 4 V.10 2005                                                 Page 3 of 4
                                                 PHOTOCOPY THIS PAGE IF MORE THAN 1 CORPORATION or 2 INDIVIDUALS

Further                                   • Forms can be lodged at your local Office of Fair Trading, Magistrates Courts
Instructions                                Offices outside Brisbane, Queensland Government Agents Offices, SmartLicence
and advice                                  or State Development Centres. Or post them to the Office of Fair Trading,
                                            GPO Box 3111, Brisbane Qld 4001.
If you need help or aren’t                • The Office of Fair Trading will not issue receipts unless specifically requested.
sure of something when                      OFT will not notify that documents have been processed.
completing this form call
13 13 04 rather than                      • Where you notify OFT of a change of proprietorship, a new Certificate of
submitting an incomplete                    Registration showing the new proprietors will be issued free of charge.
or incorrect form.                          A new Certificate of Registration will not be issued for any other changes.


Part 3 – Proprietor Name Change
1. Name Change
of Proprietor                             Former name ....................................................................................................................
(Do not use for change in
proprietorship)                           New name ........................................................................................................................
Insert details where the name
of an individual or corporation           Date of change                     /           /
carrying on business has
changed and the date of change.


Part 4 – Signatures
                                          In signing this, I hereby declare that the information is true and
                                          correct in every detail.
Signatures                                Individuals
This section must be
completed.
                                  (i)     Full name ..........................................................................................................................
A signature from only one                 Signature ................................................................. Date                  /           /
proprietor is required if
changes have been made to
business details only (Part 1
                                  (ii)    Full name ..........................................................................................................................
of this form).                                                                                                                              /           /
                                          Signature ................................................................. Date
For changes in proprietorship
(Part 2) a signature is           (iii)   Full name ..........................................................................................................................
required from each person
ceasing, continuing, or                   Signature ................................................................. Date                  /           /
commencing to carry on the
business.
                                          Corporations
For changes in the
proprietor’s name (Part 3) the    (i)     Corporation / Company name .............................................................................................
signature of the individual or
of a director or secretary of             Full name of signatory ......................................................................................................
the corporation whose name
has changed is required.                  Position of signatory in company                          Director                Company Secretary
For Corporations the
signatory must be a director              Specify equivalent position if not a company ...................................................................
or secretary only.
                                          Signature .................................................................. Date                 /           /

                                  (ii)    Corporation / Company name .............................................................................................

                                          Full name of signatory ......................................................................................................

                                          Position of signatory in company                          Director                Company Secretary

                                          Specify equivalent position if not a company ...................................................................

                                          Signature .................................................................. Date                 /           /

                                          Have all relevant persons signed above?
                                          An address change in Part 1-2, 1-3 or 1-6 only requires the signature of one proprietor.
                                          Business Names Act 1962 • Section 12 (1) (a), 2 3 & 4 • Form 4 V.10 2005                                                Page 4 of 4

				
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