F10

(No title)

Company name

.................................................................................

Company number (if applicable)

.................................................................................

Country of incorporation (if not Fiji)

.................................................................................

Unit number/Level/Office building

.................................................................................

Street number and street

.................................................................................

Suburb/City

.................................................................................

Island/State/Territory

.................................................................................

Postcode

.................................................................................

Country (if not Fiji)

.................................................................................

Court: High Court of Fiji

Application No: .................................................................................

Date of order: .................................................................................

Name and address of liquidator:

Surname

.................................................................................

First name(s)

.................................................................................

Unit number/Level/Office building

.................................................................................

Street number and street

.................................................................................

Suburb/City

.................................................................................

Island/State/Territory

.................................................................................

Postcode

.................................................................................

Country (if not Fiji)

.................................................................................

Signature

I certify that the information in this form is true and complete.

Name

.................................................................................

Signature ................................................................

Date signed .................................. / .................................. / ..................................