Group Member Registration Form - Quintis Class Action

Home » Group Member Registration Form – Quintis Class Action

To register for the Davis Class Action please complete this form

NOTE: You do not need to complete and return this form if you have previously registered for the Davis Class Action with Piper Alderman or LCM, and provided to Piper Alderman or LCM the trade information requested below.

Quintis Class Action – Davis & Anor v Quintis Limited & Ors

Are you registering on behalf of a corporation or individual?(Required)

Name of Organisation(Required)

Full name of group member(Required)

Title First Middle Last

Registered owner of shares(Required)

Registered owner is same as the above

Registered owner is different to the above

Registered owner of shares (if different from name of group member)(Required)

Security Reference Number (SRN) or Holder Identification Number (HIN)(Required)

Full name of person completing this form(Required)

Title e.g. Mr/Mrs/Dr First Middle Last

Authority of person completing this form (for example, a person completing this form in their capacity as the registered owner of the shares, director, lawyer, attorney etc)(Required)

Telephone contact(Required)

Email address(Required)

Mailing Information

Postal address(Required)

Street Address Address Line 2 City State Post Code Country

Trade Information

How many Quintis Ltd shares did you hold at the commencement of trading on 31 August 2015?(Required)

Did you purchase any Quintis Ltd shares prior to 31 August 2015 that you held (did not sell) until 15 May 2017?(Required)

Yes

In the section below, list the details of all transactions and trades in Quintis Ltd shares between 31 August 2015 to 15 May 2017 (inclusive) (Claim Period) and all transactions and trades in Quintis Ltd shares made prior to 31 August 2015 and held during the Claim Period.

Trade Information 1

Trade 1 Date(Required)

Trade 1 Transaction(Required)

Trade 1 Number of Shares(Required)

Please enter a number from 1 to 20000000.

Trade 1 $ Unit Price per Share(Required)

$ Total Trade 1 (Calculated)

Do you need to provide information for a second trade?(Required)

Yes

Trade Information 2

Trade 2 Date(Required)

Trade 2 Transaction(Required)

Trade 2 Number of Shares(Required)

Please enter a number from 1 to 20000000.

Trade 2 $ Unit Price per Share(Required)

$ Total Trade 2 (Calculated)

Do you need to provide information for a third trade?(Required)

Yes

Trade Information 3

Trade 3 Date(Required)

Trade 3 Transaction(Required)

Trade 3 Number of Shares(Required)

Please enter a number from 1 to 20000000.

Trade 3 $ Unit Price per Share(Required)

$ Total Trade 3 (Calculated)

Do you need to information of a fourth trade?(Required)

Yes

Trade Information 4

Trade 4 Date(Required)

Trade 4 Transaction(Required)

Trade 4 Number of Shares(Required)

Please enter a number from 1 to 20000000.

Trade 4 $ Unit Price per Share(Required)

$ Total Trade 4 (Calculated)

Do you need to provide information for a fifth trade?(Required)

Yes

Trade Information 5

Trade 5 Date(Required)

Trade 5 Transaction(Required)

Trade 5 Number of Shares(Required)

Please enter a number from 1 to 20000000.

Trade 5 $ Unit Price per Share(Required)

$ Total Trade 5 (Calculated)

Do you need to provide information for a sixth trade?(Required)

Yes

Trade Information 6

Trade 6 Date(Required)

Trade 6 Transaction(Required)

Trade 6 Number of Shares(Required)

Please enter a number from 1 to 20000000.

Trade 6 $ Unit Price per Share(Required)

$ Total Trade 6 (Calculated)

Do you need to provide information for a seventh trade?(Required)

Yes

Trade Information 7

Trade 7 Date(Required)

Trade 7 Transaction(Required)

Trade 7 Number of Shares(Required)

Please enter a number from 1 to 20000000.

Trade 7 $ Unit Price per Share(Required)

$ Total Trade 7 (Calculated)

Do you need to provide information for an eighth trade?(Required)

Yes

Trade Information 8

Trade 8 Date(Required)

Trade 8 Transaction(Required)

Trade 8 Number of Shares(Required)

Please enter a number from 1 to 20000000.

Trade 8 $ Unit Price per Share(Required)

$ Total Trade 8 (Calculated)

Do you need to provide information for a ninth trade?(Required)

Yes

Trade Information 9

Trade 9 Date(Required)

Trade 9 Transaction(Required)

Trade 9 Number of Shares(Required)

Please enter a number from 1 to 20000000.

Trade 9 $ Unit Price per Share(Required)

$ Total Trade 9 (Calculated)

Do you need to provide information for a tenth trade?(Required)

Yes

Trade Information 10

Trade 10 Date(Required)

Trade 10 Transaction(Required)

Trade 10 Number of Shares(Required)

Please enter a number from 1 to 20000000.

Trade 10 $ Unit Price per Share(Required)

$ Total Trade 10 (Calculated)

Do you need to provide information for an eleventh trade?(Required)

Yes

Trade Information 11

Trade 11 Date(Required)

Trade 11 Transaction(Required)

Trade 11 Number of Shares(Required)

Please enter a number from 1 to 20000000.

Trade 11 $ Unit Price per Share(Required)

$ Total Trade 11 (Calculated)

Do you need to provide information for a twelth trade?(Required)

Yes

Trade Information 12

Trade 12 Date(Required)

Trade 12 Transaction(Required)

Trade 12 Number of Shares(Required)

Please enter a number from 1 to 20000000.

Trade 12 $ Unit Price per Share(Required)

$ Total Trade 12 (Calculated)

Do you need to provide information for a thirteenth trade?(Required)

Yes

Trade Information 13

Trade 13 Date(Required)

Trade 13 Transaction(Required)

Trade 13 Number of Shares(Required)

Please enter a number from 1 to 20000000.

Trade 13 $ Unit Price per Share(Required)

$ Total Trade 13 (Calculated)

Do you need to provide information for a fourteenth trade?(Required)

Yes

Trade Information 14

Trade 14 Date(Required)

Trade 14 Transaction(Required)

Trade 14 Number of Shares(Required)

Please enter a number from 1 to 20000000.

Trade 14 $ Unit Price per Share(Required)

$ Total Trade 14 (Calculated)

Do you need to provide information for a fifteenth trade?(Required)

Yes

Trade Information 15

Trade 15 Date(Required)

Trade 15 Transaction(Required)

Trade 15 Number of Shares(Required)

Please enter a number from 1 to 20000000.

Trade 15 $ Unit Price per Share(Required)

$ Total Trade 15 (Calculated)

Do you need to provide information for a sixteenth trade?(Required)

Yes

Trade Information 16

Trade 16 Date(Required)

Trade 16 Transaction(Required)

Trade 16 Number of Shares(Required)

Please enter a number from 1 to 20000000.

Trade 16 $ Unit Price per Share(Required)

$ Total Trade 16 (Calculated)

Do you need to provide information for a seventeenth trade?(Required)

Yes

Trade Information 17

Trade 17 Date(Required)

Trade 17 Transaction(Required)

Trade 17 Number of Shares(Required)

Please enter a number from 1 to 20000000.

Trade 17 $ Unit Price per Share(Required)

$ Total Trade 17 (Calculated)

Do you need to provide information for an eighteenth trade?(Required)

Yes

Trade Information 18

Trade 18 Date(Required)

Trade 18 Transaction(Required)

Trade 18 Number of Shares(Required)

Please enter a number from 1 to 20000000.

Trade 18 $ Unit Price per Share(Required)

$ Total Trade 18 (Calculated)

Do you need to provide information for a nineteenth trade?(Required)

Yes

Trade Information 19

Trade 19 Date(Required)

Trade 19 Transaction(Required)

Trade 19 Number of Shares(Required)

Please enter a number from 1 to 20000000.

Trade 19 $ Unit Price per Share(Required)

$ Total Trade 19 (Calculated)

Do you need to provide information for a twentieth trade?(Required)

Yes

Trade Information 20

Trade 20 Date(Required)

Trade 20 Transaction(Required)

Trade 20 Number of Shares(Required)

Please enter a number from 1 to 20000000.

Trade 20 $ Unit Price per Share(Required)

$ Total Trade 20 (Calculated)

Do you need to provide information for additional trades?(Required)

Yes

Additional Trade Information

If you need to add additional trade information - please use the File Upload option below.

Supporting Documents

File Upload (optional)

Please upload any supporting documents you hold for the above transactions, for example, any buy or sell confirmations, transaction summaries, and/ or any CHESS holding statements’

Drop files here or

Accepted file types: jpg, pdf, png, gif, doc, docx, xls, xlsx, csv, zip, Max. file size: 2 MB.

Confirmation

CAPTCHA

Quintis Class Action – Davis & Anor v Quintis Limited & Ors

Mailing Information

Trade Information

In the section below, list the details of all transactions and trades in Quintis Ltd shares between 31 August 2015 to 15 May 2017 (inclusive) (Claim Period) and all transactions and trades in Quintis Ltd shares made prior to 31 August 2015 and held during the Claim Period.

Trade Information 1

Trade Information 2

Trade Information 3

Trade Information 4

Trade Information 5

Trade Information 6

Trade Information 7

Trade Information 8

Trade Information 9

Trade Information 10

Trade Information 11

Trade Information 12

Trade Information 13

Trade Information 14

Trade Information 15

Trade Information 16

Trade Information 17

Trade Information 18

Trade Information 19

Trade Information 20

Additional Trade Information

Supporting Documents

Confirmation

Adelaide

Brisbane

Melbourne

Perth

Sydney

Connect:

Quintis Class Action – Davis & Anor v Quintis Limited & Ors

Mailing Information

Trade Information

In the section below, list the details of all transactions and trades in Quintis Ltd shares between 31 August 2015 to 15 May 2017 (inclusive) (Claim Period) and all transactions and trades in Quintis Ltd shares made prior to 31 August 2015 and held during the Claim Period.

Trade Information 1

Trade Information 2

Trade Information 3

Trade Information 4

Trade Information 5

Trade Information 6

Trade Information 7

Trade Information 8

Trade Information 9

Trade Information 10

Trade Information 11

Trade Information 12

Trade Information 13

Trade Information 14

Trade Information 15

Trade Information 16

Trade Information 17

Trade Information 18

Trade Information 19

Trade Information 20

Additional Trade Information

Supporting Documents

Confirmation

Pay my invoice

Want to be kept up-to-date?

Subscribe

Adelaide

Brisbane

Melbourne

Perth

Sydney

Connect:

Subscribe: