CONSENT TO ACT AS PUBLIC OFFICER

________ (ACN ________)

(the "Company")

To: The Directors

________
________

Date: ________

Dear Directors,

Re: Consent to Act as Public Officer of the Company

§1 — Consent to Appointment

1. I, the person named below, hereby consent to my appointment as the Public Officer of the Company pursuant to section 252 of the Income Tax Assessment Act 1936 (Cth), and where applicable section 444-30 of Schedule 1 to the Taxation Administration Act 1953 (Cth) and any other applicable taxation legislation.
2. This consent takes effect on and from ________ and continues until I cease to hold office in accordance with law.

§2 — Eligibility and Acknowledgements

1. I confirm that I have attained the age of 18 years.
2. I confirm that I ordinarily reside in Australia, as required for a person to be appointed and to act as a Public Officer.
3. I confirm that I am not disqualified, under any Commonwealth or State law, from acting as a Public Officer of the Company.
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5. I acknowledge that the appointment of a Public Officer must be made within three months after the Company commences to carry on business or first derives income in Australia, and undertake to notify the Company promptly of any change to the particulars set out below.

§3 — Particulars of Public Officer

Full name: ________

Date of birth: ________

Tax file number: ________

Residential address:

________

Address for service of notices:

________

Contact telephone: ________

Email address: ________

§4 — Privacy

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§5 — Governing Law

1. This consent is governed by the laws of ________ and the Commonwealth of Australia.

EXECUTED as a deed.

SIGNED by ________ on the ________ day of ________ 20________.

..................................................
Signature of Public Officer
________

In the presence of:

................................................
Witness Signature

................................................
Witness Name: ________

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Witness Occupation: ________

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Witness Address: ________