FORM 2
NOTIFICATION OF BECOMING A REGISTERED TITLEHOLDER AFTER 1 JANUARY 2012
in accordance with
Subsection 286A(2) of the Offshore Petroleum and Greenhouse Gas Storage Act 2006
TITLEHOLDER TO COMPLETE THE INFORMATION BELOW AND GIVE NOPTA AND
NOPSEMA THE COMPLETED FORM WITHIN 30 DAYS OF BECOMING A REGISTERED
TITEHOLDER
To
National Offshore Petroleum Safety and Environmental Management Authority
National Offshore Petroleum Titles Administrator
Post
NOPSEMA- GPO Box 2568, WA 6001
NOPTA - GPO Box 7871, WA 6850
Phone
NOPSEMA - 08 6188 8700
NOPTA - 08 6424 5301
E-mail
submissions@nopsema.gov.au
titles@nopta.gov.au
Office
Hours
8:00 – 17:00 Mon – Fri
NOTICE
Pursuant to subsection 286A(2) of the Offshore Petroleum and Greenhouse Gas Storage Act 2006,
[Name of registered titleholder] gives notice of having become a/the registered holder of a petroleum
title after 1 January 2012, as set out below.
TITLE NUMBER
REQUIRED:
Registered Titleholder’s Name
Business Address (if Individual)
Head Office or a Principal Office
Address (if body corporate)
ACN
Date of becoming a Registered
Titleholder
Registered Titleholder’s Phone
Registered Titleholder’s Fax (if any)
Registered Titleholder’s Email
OPTIONAL:
Contact Person
Position Held
Contact Phone
Contact Email
TITLEHOLDER CONTACT DETAILS
Where the registered holder is an individual:
SIGNED
DATE
* Before completing this form, please refer to the notes section on page 3 *
Notification of Becoming a Registered Titleholder after 1 January 2012 [version two]
Page 1
WHERE THE REGISTERED HOLDER IS A COMPANY
If the registered holder is a company then use the following Signature Block. A company must have
two of its directors sign below. Alternatively if there is only one Director, then it needs to be signed by
the Director and the Company Secretary. If there is only one Director, who is also the Company
Secretary, then only that person needs to sign.
EXECUTED BY
[insert Company Name]
____________________________
Signature
________________________
Signature
____________________________
Date
________________________
Date
____________________________
Full name (please print)
________________________
Full name (please print)
____________________________
Position (Director or Secretary)
DIRECTOR
Where only one person signs above then that person warrants that they are the sole Director
and Secretary of the company.
In the Presence of:
In the Presence of:
____________________________
WITNESS
________________________
WITNESS
____________________________
________________________
Please print full name and occupation or profession of witnesses above.
Notification of Becoming a Registered Titleholder after 1 January 2012 [version two]
Page 2
NOTES
TITLEHOLDER PLEASE NOTE:
1.
THIS FORM IS FOR EACH PERSON WHO BECOMES A REGISTERED HOLDER OF A
PETROLEUM TITLE IN COMMONWEALTH WATERS AFTER 1 JANUARY 2012.
2.
IN THE CASE OF MULTIPLE TITLEHOLDERS, EACH OF THE REGISTERED HOLDERS IS
REQUIRED TO COMPLETE A SEPARATE FORM UPON BECOMING A TITLEHOLDER.
3.
A SEPARATE FORM IS REQUIRED FOR EACH TITLE.
4.
FAILURE TO COMPLETE AND GIVE THIS FORM TO NOPTA AND NOPSEMA WITHIN 30
DAYS OF AFTER BECOMING A REGISTERED IS AN OFFENCE – SEE SUBSECTION 286A(7)
OF THE OFFSHORE PETROLEUM AND GREENHOUSE GAS STORAGE ACT 2006.
Notification of Becoming a Registered Titleholder after 1 January 2012 [version two]
Page 3