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Share Application Form
Genetics Australia Co-operative Limited
“Parwan Park”, Woolpack Road, Bacchus Marsh, Victoria
Postal Address: PO Box 195, Bacchus Marsh, Victoria, 3340
Application for Membership
PLEASE USE BLOCK LETTERS THROUGHOUT
Surname of Applicant/Company Representative_____________________________________
Given Names ___________________________________________________________
Company Name ___________________________________ABN ________________________
(1) If applicant is a partnership, full names of all partners required.
(2) If applicant is an Incorporated Company, name of company representative required.
Postal Address _________________________________________________________
__________________________________________________ Postcode ______________
Telephone Number ______________________________________________________
Occupation _____________________________ Shire/Farm Number _____________
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I hereby apply to be admitted as a member of the abovenamed Co-operative
and to be allotted 50 shares of $2.00 each therein,
on which
70 cents per share is payable with application and in
respect of this
application I lodge herewith in accordance with rules the
sum of $ 35.
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I am able to meet the Active Membership requirements of the Co-operative, namely purchasing Genetics Australia products or services to the value of $100 or more over a 12 month period.
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If this application is approved and the shares as aforesaid be allotted to me,
I agree to be bound by the Rules of the Co-operative in accordance with the Co-operatives Act 1996.
Dated this __________ day of ________________________ , 20 ______
______________________________________________________________
(Signature of Applicant)
______________________________________________________________
(Witness)
OFFICE USE ONLY
Application No. _____________ Date Application Received ____/____/____
Receipt No. ____________________ Shares Allotted ____________________
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