Amico New Zealand Limited

COMPANY FORMATION - PRINTABLE ORDER FORM

For our services we charge [NZ currency] :

To enable us to perform the incorporation of your new company, please complete all sections and

- fax this form including your Credit Card details
  to (03) 329 5053 or from overseas to +64 3329 5053

- mail this form together with your NZ$-cheque
   (please make the cheque payable to our payment provider "IPAYU LIMITED, Christchurch")
   to our address at AMICO NEW ZEALAND LIMITED, PO BOX 139, LINCOLN 7640, NEW ZEALAND

For the incorporation of your new company, we need to know:

Proposed Company Name (Preferred choice) (Alternative name)       Number of Shares         Address of Registered Office   [has to be a physical address]   Address for Service   [has to be a physical address]   Shall we act as the Registered Office and Address for Service for your company? yes   Company Postal Address   [can be even a P.O.Box]    Would you like to use our mail-forwarding service for your company? yes   Shareholders Surname First Name(s) Residential Address Shares           Directors Surname First Name(s) Residential Address               Your First Name Your Surname Postal Address    Daytime Phone Fax E-mail   necessary to contact you        Credit Card Type MasterCardVISA Card holder's Full Name Card Number CSV Number Expiry Date  mm/yy format Card Holder's Address (if different from above)   Payment charged NZ$297.00 - incorporation, including all official fees NZ$997.00 - incorporation, registered office, mail forwarding NZ$340.00 - mail forwarding $240 + first postage deposit $100   Comments Please enter any special requirements or other information here.   If you fax or post of this form to us you accept our "Terms of Service" Please make sure you have read them before.

Copyright © 1999-2010 Amico New Zealand Limited - All rights reserved.

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