Companies Act 1993 Amendment Regulations (No 2) 2014

Form 12
Annual return

Section 214(1), Companies Act 1993

If there is insufficient space on the form to supply the information required, attach a separate sheet containing the information set out in the prescribed format.

Company name:

Company No:

Address for communication

Address of registered office:

Address for service:

Email address (to receive email reminders):

Mobile telephone No* (to receive text reminders in addition to email reminders):

*The costs of any message will be charged to your phone.
Company directors

Provide the following information in the prescribed format for every director.

First name(s):*

Surname:*

Full residential address:

*Provide full legal name.
Details of ultimate holding company

Registered name:

Country of registration:

Registered number or identifier:

Address of registered office:*

Address for service:†

*The address of the registered office must be provided if the company is required by its country of registration to have a registered office.
†The address for service is not required if the address of the registered office has been provided.
Share parcels

Total number of shares issued:

Largest shareholders

Provide the following information in the prescribed format for the persons holding the 10 largest numbers of shares in the company.

Number of shares in share parcel:

Full legal name of shareholder:*

Address of shareholder:†

*In the case of a natural person, please provide the first name(s) followed by the surname in block letters. If the trustees of a trust (for example, a family trust) are not incorporated under the Charitable Trusts Act 1957 or another Act, the names of all the trustees must be shown and the shares recorded as being jointly held by them.

†If the shareholder is a natural person, please provide a residential address. If the shareholder is a body corporate, please provide the address of its registered office or, if it does not have a registered office, the address of its principal place of business.

Other shareholders

Does the company have more than 10 share parcels? Yes/No*

*Select one.

If the company is not a party to a listing agreement with a registered exchange, please provide the names and addresses of, and the number of shares held by, the other shareholders of the company on a separate sheet or sheets set out in the prescribed manner.

Number of shares in share parcel:

Full legal name of shareholder:

Address of shareholder:

Authorised person

I certify that the particulars contained in this annual return are correct.

Date:

Full legal name of authorised person:

Title of authorised person:

Signature of authorised person:

Details of person completing this return

Name:

Title:

Address:

Email address:

Telephone No:

Fax No (if any):