Application - Package 4 - The Compensation for Occupational Injuries and Diseases Act

Application Form

Full Name of Applicant*

Please fill in your First Name and Last Name

Telephone

Cell Phone*

Please type in your mobile number

Email

Company Details

1st Proposed name of company*

2nd Proposed name of company*

3rd Proposed name of company*

4th Proposed name of company*

Description of principle business activity*

Business Physical Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Business Postal Address*

Full Postal address for this company.

Company Financial Year end*

Preferred financial year end (usually 28 Feb)

Special Requirements

Number of Directors

Please select the number of directors in your company.

Director 1 : Details

Name

FirstLast

ID / Passport Number*

% Shareholding*

Please enter a value between 0 and 100.

Please enter the % shareholding for this Director

Physical Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Postal address*

Full Postal address for this director.

Director 2 : Details

Name

FirstLast

ID / Passport Number*

% Shareholding*

Please enter a value between 0 and 100.

Please enter the % shareholding for this Director

Physical Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Postal address*

Full Postal address for this director.

Director 3 : Details

Name

FirstLast

ID / Passport Number*

% Shareholding*

Please enter a value between 0 and 100.

Please enter the % shareholding for this Director

Physical Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Postal address*

Full Postal address for this director.

Director 4 : Details

Name

FirstLast

ID / Passport Number*

% Shareholding*

Please enter a value between 0 and 100.

Please enter the % shareholding for this Director

Physical Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Postal address*

Full Postal address for this director.

Director 5 : Details

Name

FirstLast

ID / Passport Number*

% Shareholding*

Please enter a value between 0 and 100.

Please enter the % shareholding for this Director

Physical Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Postal address*

Full Postal address for this director.

Director 6 : Details

Name

FirstLast

ID / Passport Number*

% Shareholding*

Please enter a value between 0 and 100.

Full Postal address for this director.

Physical Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Postal address*

Full Postal address for this director.

Director 7 : Details

Name

FirstLast

ID / Passport Number*

% Shareholding*

Please enter a value between 0 and 100.

Please enter the % shareholding for this Director

Physical Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Postal address*

Full Postal address for this director.

Director 8 : Details

Name

FirstLast

ID / Passport Number*

% Shareholding*

Please enter a value between 0 and 100.

Please enter the % shareholding for this Director

Physical Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Postal address*

Full Postal address for this director.

Director 9 : Details

Name

FirstLast

ID / Passport Number*

% Shareholding*

Please enter a value between 0 and 100.

Please enter the % shareholding for this Director

Physical Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Postal address*

Full Postal address for this director.

Director 10 : Details

Name

FirstLast

ID / Passport Number*

% Shareholding*

Please enter a value between 0 and 100.

Please enter the % shareholding for this Director

Physical Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Postal address*

Full Postal address for this director.

Shareholder's that are not Directors of this company

Are there any shareholders that are not directors of this company?*

Yes
No

Number of Shareholders

Please select the number of directors in your company.

Shareholder 1 (non-director) : Details

Name

FirstLast

ID / Passport Number*

% Shareholding*

Please enter a value between 0 and 100.

Please enter the % shareholding for this Director

Physical Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Postal address*

Full Postal address for this director.

Shareholder 2 (non-director) : Details

Name

FirstLast

ID / Passport Number*

% Shareholding*

Please enter a value between 0 and 100.

Please enter the % shareholding for this Director

Physical Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Postal address*

Full Postal address for this director.

Shareholder 3 (non-director) : Details

Name

FirstLast

ID / Passport Number*

% Shareholding*

Please enter a value between 0 and 100.

Please enter the % shareholding for this Director

Physical Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Postal address*

Full Postal address for this director.

Shareholder 4 (non-director) : Details

Name

FirstLast

ID / Passport Number*

% Shareholding*

Please enter a value between 0 and 100.

Please enter the % shareholding for this Director

Physical Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Postal address*

Full Postal address for this director.

Shareholder 5 (non-director) : Details

Name

FirstLast

ID / Passport Number*

% Shareholding*

Please enter a value between 0 and 100.

Please enter the % shareholding for this Director

Physical Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Postal address*

Full Postal address for this director.

Shareholder 6 (non-director) : Details

Name

FirstLast

ID / Passport Number*

% Shareholding*

Please enter a value between 0 and 100.

Please enter the % shareholding for this Director

Physical Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Postal address*

Full Postal address for this director.

Shareholder 7 (non-director) : Details

Name

FirstLast

ID / Passport Number*

% Shareholding*

Please enter a value between 0 and 100.

Please enter the % shareholding for this Director

Physical Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Postal address*

Full Postal address for this director.

Shareholder 8 (non-director) : Details

Name

FirstLast

ID / Passport Number*

% Shareholding*

Please enter a value between 0 and 100.

Please enter the % shareholding for this Director

Physical Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Postal address*

Full Postal address for this director.

Shareholder 9 (non-director) : Details

Name

FirstLast

ID / Passport Number*

% Shareholding*

Please enter a value between 0 and 100.

Please enter the % shareholding for this Director

Physical Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Postal address*

Full Postal address for this director.

Shareholder 10 (non-director) : Details

Name

FirstLast

ID / Passport Number*

% Shareholding*

Please enter a value between 0 and 100.

Please enter the % shareholding for this Director

Physical Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Postal address*

Full Postal address for this director.

Comments

This field is for validation purposes and should be left unchanged.

Application – Package 4

Package 4

Application Form

Company Details

Director 1 : Details

Director 2 : Details

Director 3 : Details

Director 4 : Details

Director 5 : Details

Director 6 : Details

Director 7 : Details

Director 8 : Details

Director 9 : Details

Director 10 : Details

Shareholder's that are not Directors of this company

Shareholder 1 (non-director) : Details

Shareholder 2 (non-director) : Details

Shareholder 3 (non-director) : Details

Shareholder 4 (non-director) : Details

Shareholder 5 (non-director) : Details

Shareholder 6 (non-director) : Details

Shareholder 7 (non-director) : Details

Shareholder 8 (non-director) : Details

Shareholder 9 (non-director) : Details

Shareholder 10 (non-director) : Details

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