Application for a Variation of a VIPA Certificate of Approval

Vanuatu Investment Promotion Act No. 15 of 1998

(Section 6)

This application form must be accompanied by the relevant fee based on the project's Total

Investment Cost (TIC) as specified below. This fee must be payable by cash or cheque to the

Vanuatu Investment Promotion Authority.

This fee is not refundable

Application fee VT. 60,000

Please submit the completed application form to;

VANUATU INVESTMENT PROMOTION AUTHORITY

PMB 9011,

PORT VILA,

VANUATU

Incomplete Application Will Be Returned

SECTION 1 - GENERAL INFORMATION AND CHECKLIST

1. Business Name (existing)

2. Name of Key Contact

3. Telephone

Type of Variation Requested and Checklist (please identify which variation(s) is applicable to you):

Change in business name Yes No

Complete and signed section 1 and 2 of the application form Yes No

Copy of business name registration certificate Yes No

Registration Certificate

Change in ownership Yes No

Completed and signed section 1 and 3 of the application form, and statutory declaration(s) Yes No

Photo-copy(s) of passport ID pages for each investor Yes No

Investor 1 Passport ID

Investor 2 Passport ID

Photo-copy of police clearance(s) for each investor intending to reside in Vanuatu Yes No

Police Clearance

Letter of support from existing owner/resident director of business Yes No

letter of support

Copy of existing business licence Yes No

Existing Business Licence

Change in business activity Yes No

Change in location of business activity Yes No

Completed and signed section 1 and 4 of the application form Yes No

Copy of existing business licence Yes No

Existing Business Licence

Business summary (if investing in a "reserved" activity) Yes No

SECTION 2 - VARIATION IN BUSINESS NAME

5. Business Name

a) Detail(s) for individuals who are owners/shareholders in the proposed investment:*

New Business Name

Name

Date

Signature

SECTION 3 - VARIATION IN OWNERSHIP

6. Investors

a) For each proposed new shareholder provide the following details:*

New Investor 1

Surname

First Name

Telephone

Primary Nationality

2nd Nationality

New Investor 2

Surname

First Name

Telephone

Primary Nationality

2nd Nationality

New Investor 3

Surname

First Name

Telephone

Primary Nationality

2nd Nationality

* Please include a photocopy of the passport ID page for each proposed new investor. Investors with more than one passport must provide photocopies for each of their passports.

b) Is another company(s) a shareholder in the investment? Yes No

If yes, attach full particulars, including: name, registered address, details of shareholders and directors, and the total percentage of shareholding by non-residents of Vanuatu.

7. Associated Businesses

Are any of the individuals or companies identified in section 6 own, or have controlling interests in, other business enterprise(s) in Vanuatu or overseas? Yes No

If yes, please provide the following details:

Name of business(s)

Names of shareholders

8. Day to day management

Will the business be managed by someone other than the foreign investor? Yes No

If yes, please provide the following:

Manager's Name

Telephone

9. Summary

(a) Type of variation in ownership being applied for (please tick appropriate box): Purchase of the entire business by a new investor(s) Adding new investors

(b) Summary of ownership

Previous Ownership

Investor Name

Share (%)

Previous Ownership

Investor Name

Share (%)

Previous Ownership

Investor Name

Share (%)

Previous Ownership

Investor Name

Share (%)

Previous Ownership

Investor Name

Share (%)

Previous Ownership

Investor Name

Share (%)

Proposed New Ownership

Investor Name

Nationality

Share (%)

Proposed New Ownership

Investor Name

Nationality

Share (%)

Proposed New Ownership

Investor Name

Nationality

Share (%)

Proposed New Ownership

Investor Name

Nationality

Share (%)

Proposed New Ownership

Investor Name

Nationality

Share (%)

Proposed New Ownership

Investor Name

Nationality

Share (%)

Investor full name