Viva Energy : ASIC Form 484 - Cancellation of Buy-Back SharesOpens in a new Window

Australian Securities & Investments Commission

Change to company details

Form 484

Corporations Act 2001

Sections A, B or C may be lodged independently with this signed cover page to notify ASIC of:

A1	Change of address	B1	Cease company officeholder	C1	Cancellation of shares
A2	Change of name - officeholders and proprietary	B2	Appoint company officeholder	C2	Issue of shares
	company members	B3	Special purpose company	C3	Change to share structure
A3	Change - ultimate holding company			C4	Changes to the register of members for proprietary
					companies
If there is insufficient space in any section of the form, you may photocopy the relevant page(s) and submit as part of this lodgement

Company details		Company name
		Viva Energy Group Limited
		ACN/ABN
		ACN 626 661 032
Refer to guide for information about		Corporate key
corporate key

Lodgement details

An image of this form will be available as part of the public register.

Who should ASIC contact if there is a query about this form?

ASIC registered agent number (if applicable)

29845

Firm/organisation

Gilbert + Tobin

Contact name/position description		Telephone number (during business hours)
Jack Culbertson / Lawyer		( 02 ) 9263 4208
Email address (optional)
[e-mail]

Postal address

L35, Tower Two, International Towers Sydney, 200 Barangaroo Avenue

	Suburb/City	State/Territory		Postcode
	Barangaroo		NSW		2000

Signature

This form must be signed by a current officeholder of the company.

I certify that the information in this cover sheet and the attached sections of this form are true and complete.

Name

Julia Kagan

Capacity

Director

• Company secretary
  Signature

Date signed

1

9

/

1

1

/

2

0

[D

D]

[M

M]

[Y

Y]

Lodgement

Send completed and signed forms to:

For more information

Australian Securities and Investments Commission,

Web

www.asic.gov.au

PO Box 4000, Gippsland Mail Centre VIC 3841.

Need help?

www.asic.gov.au/question

Or lodge the form electronically by visiting the ASIC website

Telephone

1300 300 630

www.asic.gov.au

ASIC Form 484

1 November 2014

Cover page

A1 Change of address

This section allows a new address to be applied to one or more purposes (ie registered office, principal place of business, company officeholder and/or proprietary company member.) You must copy and attach another Section A1 for each new address.

New address

A PO Box is only allowed for a member address

At the office of, C/- (if applicable)

Office, unit, level, or PO Box number (A PO Box is only allowed for a member address)

Street number and Street name

Suburb/City			State/Territory
Postcode	Country (if not Australia)

Date of change

For members' address changes, use the date of change to the members' register

Apply address to

You can apply the new address to one or more of the following - registered office, principal place of business, etc.

Registered office address

A change to the registered office address takes effect either 7 days after lodgement of the notice or a later date specified in the notice.

Date of change
[D	D] / [M	M] / [Y	Y]

Registered office address

If the registered office has changed, does the company occupy the premises? yes

no

if no, name of occupier?

Occupier's consent (Select box to indicate the statement below is correct)

The occupier of the premises has consented in writing to the use of the specified address as the address of the registered office of the company and has not withdrawn that consent.

Principal place of business address

Company officeholder's residential address

Family name

Given names

1

Date of birth

/

/

[D

D]

[M

M]

[Y

Y]

Place of birth (town/city)

(state/country)

Family name

Given names

2

Date of birth

/

/

[D

D]

[M

M]

[Y

Y]

Place of birth (town/city)

(state/country)

Proprietary company member's address

If there are more than 20 members in a share class, only address changes for the top 20 need be notified.

		Proprietary company member's address
		Family name		Given names
	1
		Family name		Given names
	2
		When a proprietary company member is a company, not an individual
		Company name (only if a member)
	1
		ACN/ ARBN/ ABN		Country of incorporation (if not Australia)

ASIC Form 484

21 November 2014

Section A Page 1 of 2

A2 Change of name - officeholders and proprietary company members

Use this section to notify a name change of an individual or organisation with one or more roles (including member of a proprietary company) in the company.

Tick one or more boxes to indicate an individual or organisation's current role in company

Personal name change

Eg change by deed poll or marriage. To appoint a new officeholder go to B2

Date of change

Organisation name change When a member of a proprietary company is an organisation, not an individual, and the organisation has changed its name

Date of change

Director

Alternate director

Proprietary company member's name

If there are more than 20 members in a share class, only

Member of proprietary

name changes for the top 20 need be notified.

Secretary

company

Date and place of birth are not required for members.

Their previous name was (provide full given names, not initials)

Family name

Given names

Date of birth

/

/

[D

D]

[M

M]

[Y

Y]

Place of birth (town/city)

(state/country)

Their new name is (provide full given names, not initials)

Family name

Given names

Date of change

/

/

[D

D]

[M

M]

[Y

Y]

The previous organisation name was

The new organisation name is

ACN/ ARBN/ ABN

Date of change
[D	D] / [M	M] / [Y	Y]

A3 Change - ultimate holding company

Use this section if there is a change to the ultimate holding company.

The change is

Date of change

There is a new ultimate holding company

Company name

ACN/ ARBN/ ABN	Country of incorporation (if not Australia)
OR

The ultimate holding company has ceased operation as the ultimate holding company

Company name

ACN/ ARBN/ ABN

OR

Country of incorporation (if not Australia)

The ultimate holding company has changed its name

Company name

ACN/ ARBN/ ABN

OR

Country of incorporation (if not Australia)

Date of change

/

/

[D

D]

[M

M]

[Y

Y]

ASIC Form 484

21 November 2014

Section A Page 2 of 2

B1 Cease company officeholder

Use this section to notify if a company officeholder has ceased to be a company officeholder. You need to notify details separately for each ceased officeholder.

Role of ceased officeholder

Select one or more boxes

Date officeholder ceased

Director

Secretary

Alternate director

Person alternate for

Date of change

/

/

[D

D]

[M

M]

[Y

Y]

Name

The name of the ceased officeholder is Family name

Date of birth

[D D] / [M M] / [Y Y] Place of birth (town/city)

Given names

(state/country)

B1 Continued... Cease another company officeholder

Use this section to notify if a company officeholder has ceased to be a company officeholder. You need to notify details separately for each ceased officeholder.

Role of ceased officeholder

Select one or more boxes

Date officeholder ceased

Director

Secretary

Alternate director

Person alternate for

Date of change

/

/

[D

D]

[M

M]

[Y

Y]

Name

The name of the ceased officeholder is Family name

Date of birth

[D D] / [M M] / [Y Y] Place of birth (town/city)

Given names

(state/country)

ASIC Form 484

21 November 2014

Section B Page 1 of 3