City, State and Country
Street number / name
Including area code
Please provide your latest bio for inclusion in Notice of Meeting, Annual reports and other public announcements. This will typical be a paragraph which will include your qualifications.
Personal Assistant's Name (please fill if applicable)
Personal Assistant's Phone Number (please fill if applicable)
Personal Assistant's Email (please fill if applicable)
Tick the box if yes
Do you have a Relevant Interest in have an interest in any of the securities issued by the Company (including shares, options, performance rights and convertible securities) where you personally are the registered holder of those securities? If yes, please provide the number and class of securities you hold.
Does any company, trust or other entity you control or have a Relevant Interest in have any interest in any of the securities issued by the Company (including shares, options, performance rights and convertible securities) excluding any securities where you are the registered holder? If yes, please provide the Holder's name, details of Relevant Interest and number and class of securities.
Do you hold any office, or have any interest in a contract or property, which has resulted in, or which may in the future lead to, a conflict of interest between your duties as a director of the Company and your personal position (including your independence as a Director)? If yes, please provide details.
Are you are a customer of any Group Company, or a shareholder in any customer of any Group Company, or an officer of, or otherwise associated with, a customer of any Group Company? If yes, please provide relevant details.
At any time in the last 3 years, have you, or any entity that you, or your family member, controls, been a party to a contract with any Group Company (other than your letter of appointment as Director)? If yes, please provide details.
In the last 3 years, have you been an officer of, or otherwise associated with, a party to a contract with any Group Company? If yes, please provide all relevant details.
Do you have any interest, or any business or other relationship, that could interfere with your ability to act in the best interests of the Company or could reasonably be perceived to cause any interference with your duties owed to the Company? If yes, please provide all relevant details.
Please provide the details of all entities of which you are currently a director and the details of any ASX-listed companies of which you have been a director in the last 3 years.
Are you, or any company, trust or associate, are a party to any contract (or otherwise entitled to a benefit under any contract) that confers a right to call for or deliver securities in, or debentures of any Group Company? If yes, please provide the details of the contract, the parties to the contract, the nature of your interest in the contract, the name of the party to whom the securities were, or could be, issued and the number and class of securities or debentures which are contemplated under the contract.
By writing 'confirmed' above, I confirm that, to the best of my knowledge: (a) the information given by me is true, accurate and complete; and (b) there is no other information that may be relevant or affect an assessment of my independence as a director of the Company.
