I am an applicant (I want to exit my holding from the original access licence). H13 I am not an applicant (I am providing consent to this application). H14 Signature Date Title (Mr, Mrs, Ms) Surname H15 H16 Given name/s H17 Address H18 Town State Postcode Country H19 H20 H21 H22 Phone Mobile phone H23 H24 Fax Email H25 H26 I am the holder of a holding in the original access licence and: (tick the appropriate box) I am an applicant (I want to exit my holding from the original access licence). H27 I am not an applicant (I am providing consent to this application). H28 Signature Date If there are more than two individuals signing Section H, attach extra copies of this page. Have extra copies of this page been attached? No Yes - specify number: H29 For applications made by a corporation: Executed for and on behalf of the applicant in accordance with section 127 of the Corporations Act 2001 Cth (if a company) or by its duly authorised officer (for other types of corporations). Company/corporation name H30 ACN or ABN H31 Address H32 Town State Postcode Country H33 H34 H35 H36 Phone Mobile phone H37 H38 Fax Email H39 H40 This company/corporation is the holder of a holding in the original access licence and: (tick the appropriate box) is an applicant (the holding is to be exited from the original access licence). H41 company/corporation’s is not an applicant (the company/corporation provides consent to this application). H42 Position of signatory company director company secretary duly authorised officer H43
H13 I am an applicant (I want to exit my holding from the original access licence). H14 I am not an applicant (I am providing consent to this application). Signature Date H15 Title (Mr, Mrs, Ms) H16 Surname H17 Given name/s H18 Address H19 Town H20 State H21 Postcode H22 Country H23 Phone H24 Mobile phone H25 Fax H26 Email I am the holder of a holding in the original access licence and: (tick the appropriate box) H27 I am an applicant (I want to exit my holding from the original access licence). H28 I am not an applicant (I am providing consent to this application). Signature Date If there are more than two individuals signing Section H, attach extra copies of this page. H29 Have extra copies of this page been attached? No Yes - specify number: For applications made by a corporation: Executed for and on behalf of the applicant in accordance with section 127 of the Corporations Act 2001 Cth (if a company) or by its duly authorised officer (for other types of corporations). H30 Company/corporation name H31 ACN or ABN H32 Address H33 Town H34 State H35 Postcode H36 Country H37 Phone H38 Mobile phone H39 Fax H40 Email This company/corporation is the holder of a holding in the original access licence and: (tick the appropriate box) H41 is an applicant (the company/corporation’s holding is to be exited from the original access licence). H42 is not an applicant (the company/corporation provides consent to this application). H43 Position of signatory company director company secretary duly authorised officer
form_licence_wmaf028_exit_co_held.docx