Nuix-Application-Form -

Part A: Contact Details

Title *

Full Name *

First

Last

Position *

Company *

Telephone *

Mobile *

Email *

Postal Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Part B: Claimant Details

Select Appropriate *

Company
Individual
Partnership
Other (Please Specify)

Please Specify *

e.g. Jointly owned with another

Claimant Name *

First

Last

Company Number *

Postal Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Part C: Details of Share Ownership

Who is the beneficial owner of the Qualifying Shares? *

owns Qualifying Shares on own behalf
is a trustee for the beneficial owner
is a nominee for the beneficial owner
is a custodian for the beneficial owner
is a responsible entity for the beneficial owner

Name of the beneficial owner of the Qualifying Shares

First

Last

-OR- attach a schedule of Beneficial Owners on the next page

Registered Owner's Holder Identification Number/ Shareholder Registration Number (if known)

Part D: Capacity of the person signing this Application Form

If the Claimant is:

An individual or individuals (for example joint shareholders) who own the Qualifying Shares on their own behalf, each individual must sign the Application Form.
A trustee that holds the Qualifying Shares on behalf of a beneficial owner (including where the Qualifying Shares are held through a superannuation fund), the trustee(s) must sign the
Application Form.
a. If the trustee(s) are individuals, each individual trustee must sign the Application Form. b. If the trustee is a company, authorised signatories (such as directors) of the company must sign the Application Form.
A company, including a responsible entity, nominee or custodian, authorised signatories (such as directors) of the company must sign the Application Form.

Please confirm the capacity in which you are signing this Application Form *

in my/our personal capacity as individual Claimant(s)
in my/our capacity as individual trustee Claimant(s)
as director and/or company secretary of the Claimant trustee
as director and/or company secretary of the Claimant company
as agent who is legally authorised to sign on behalf of the Claimant

Please Specify

(e.g. power of attorney, solicitor, general counsel, accountant, investment manager)

Nuix-Application-Form

Part A: Contact Details

Part B: Claimant Details

Part C: Details of Share Ownership

-OR- attach a schedule of Beneficial Owners on the next page

Part D: Capacity of the person signing this Application Form

If applicable, upload Company Seal on the next page