Norfolk Corporate Support - Change of Company Name Order Form

ORDER FOR COMPANY NAME CHANGES

APPLICANT DETAILS
Contact Person: *
Company:
Address for correspondence:
Suburb/State/Postcode:
Country:
Phone: *
Email: *
Address for Delivery of Documents:
Suburb/State/Postcode:
Country:

COMPANY NAME CHANGE
CURRENT NAME OF COMPANY: *
REGISTERED OFFICE ADDRESS:*
NEW (INTENDED) NAME OF COMPANY: *
SECOND PREFERENCE
MAIN SIGNATORY FOR FORM: *

Has this name been reserved already?	No Yes
If yes, please provide details of person who signed ASIC Form 410 (Reservation Forms): If yes, please also provide a letter releasing the reserved name, signed by the person listed at right. (faxed and scanned copies are fine.) This just proves that the person who originally reserved the name withdraws their reservation for Incorporation to proceed. Please tick only when signed letter above is received from client.	Surname*
	Given Names*
	Address*
	Suburb*
	State* Postcode*
	Date of Birth*
	Town of Birth*
	Country / State*

MAIN SIGNATORY
Please either complete details below of current directors and members OR email or fax us an up to date company report or annual review.
#1
Surname:*
Given Names:*
Address:*
Suburb/State/Postcode:*
Date of Birth:*
Place of Birth:*
ALL OTHER DIRECTORS' DETAILS

DETAILS OF MEMBERS
#1
Surname:
Given Names:
Address:
Suburb/State/Postcode:
Class of Shares:
Number of Shares Held
Are the Shares Beneficially Owned?	Yes No
ALL OTHER MEMBERS' DETAILS
If company is involved, please provide its ACN & Registered Address:

Any additional information or instructions?

I * have read over the information supplied and confirm that it is correct. I understand that typing/spelling errors or incorrect information given is my responsibility and additional costs will be incurred to correct errors in order forms.
Date : *

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