Name Change - Statutory Declaration - Change of Name - Statutory

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Name Change - Statutory Declaration - Change of Name - Statutory Powered By Docstoc
					Company or Trust in which Securityholding is held
                                                                                                                                                        All correspondence to:
                                                                                                                        Computershare Investor Services Pty Limited
                                                                                                                                                   GPO Box 2975 Melbourne
Registered                                                                                                                                             Victoria 3001 Australia
                                                                                                                                    Enquiries (within Australia) 1300 850 505
Name(s)                                                                                                                                   (outside Australia) 61 3 9415 4000
                                                                                                                                                    Facsimile 61 3 9473 2500


                                                                                                                         Securityholder Reference Number (SRN)

Use a black pen.                                                              Where a choice is required,
Print in CAPITAL letters.     A B C                  1 2 3                    mark the box with an ‘X’       X

Change of Name - Statutory Declaration
A       Change of Name
        This declaration may only be used for name changes as a result of holders reverting from a married name to a maiden/former name.
        Description of Securities                                            Number of Securities held

        Full maiden/former name

                                                                                                            Maiden                    Former
        I do solemnly and sincerely declare that I chose to be known by my                                                                   as shown above
                                                                                                            Name                      Name
                        Day                  Month              Year
        from the date                       /                  /                       and that I am one and the same as the name listed currently on the register.

        There has been no change in beneficial ownership and I request my full and correct name as stated above be recorded on the register.

        I have attached                         a certified copy of my                           certified copies of 2 forms of photo identification, one in the name as it
                                                marriage certificate.                            appears on the register AND the other in the maiden/former name.
        and I make this solemn declaration:                                             · the Oaths Act 1867 (Qld.) if this declaration is made in Queensland;
        1. conscientiously believing it to be true;                                     · the Oaths Act 1936 (S.A.) if this declaration is made in South Australia;
        2. knowing that a person making a false declaration is liable to the            · the Oaths Act (N.T.) if this declaration is made in the Northern Territory;
           penalties of perjury, and                                                    · the Evidence Act 1906 (W.A.) if this declaration is made in Western
        3. by virtue of the provisions of:                                              Australia;
        · the Evidence Act 1958 if this declaration is made in Victoria;                · the Evidence Act 1910 (Tas.) if this declaration is made in Tasmania; or
        · the Oaths Act 1900 (N.S.W.) if this declaration is made in New South          · the Statutory Declarations Act 1959 (Cwth.) if this declaration is made in
        Wales;                                                                            the Australian Capital Territory or Norfolk Island.
        In consideration of the security issuer amending the register I/we hereby covenant to indemnify and forever keep indemnified the security issuer, the
        directors and trustees of the security issuer, Computershare Investor Services Pty Limited and the directors and officers of Computershare Investor
        Services Pty Limited from and against all losses in respect thereof and all claims, actions, proceedings, demands, costs and expenses whatsoever
        which may be made or brought against them by reason of compliance with this request.

B       Sign here – This section must be signed and witnessed for your instructions to be executed.
        Please complete this statutory declaration in accordance with the laws of the country in which it is declared and ensure it is legally witnessed.

        Declared at
                        (insert place where you are making the declaration)

        in                                                               on                                            signature
                        (insert State in which you are making the declaration) (insert date)                                         (insert your signature as the person making the declaration)

        Before me
                        (signature of person witnessing your declaration)(see reverse side for       (name and title of the person witnessing your declaration)
                        details of who this might be)

                                                                   CNSA                                                                                                        04/06/04
How to complete this form

A         Change of Name
          Complete this section with the full maiden/former names, indicate which name that you wish to use and enter the date you
          commenced using this name.

B         Signature(s)
          You must sign this form in the spaces provided:
          Declarant:                            the applicant named on this form must sign.
          Witness:                              to be signed in the presence of an authorised witness with their normal signature.

Persons who may witness this statutory declaration in your State:

            New South Wales                                               Western Australia                                        Victoria
            Justice of the Peace                                          Justice of the Peace                                     Justice of the Peace
            Solicitor                                                     Notary Public                                            Notary Public

            Notary Public                                                 Solicitor                                                Solicitor
                                                                          Electoral Registrar                                      Barrister
                                                                          Postmaster                                               Certain Court Officers
            Queensland                                                    Policeman                                                Policeman
            Justice of the Peace                                          Bank Manager                                             Member of Parliament
            Barrister                                                     Building Society Secretary                               Councillor
                                                                          Building Society Officer                                 Medical Practitioner

            Conveyancer                                                                                                            Dentist
            Notary Public                                                 Tasmania                                                 Veterinary Surgeon
            Commissioner for taking affidavits                            Justice of the Peace                                     Pharmacist
                                                                          Commissioner for declarations                            School Principal
                                                                                                                                   Bank Manager
            South Australia                                                                                                        Certain Accountants
            Justice of the Peace                                          ACT or Norfolk Island                                    Minister of Religion
            Bank Manager                                                  Justice of the Peace                                     Fellow of the Institute of
            Building Society Manager                                      Notary Public                                            Legal Executives (Victoria)
            Credit Union Manager
            Postmaster                                                    Northern Territory
                                                                          Any person over 18
            Commissioner for taking affidavits
            Notary Public

If you are not in Australia then any person authorised by the law of your country to administer an oath or any Australian consular officer may witness this declaration