Application for Membership Form - Global CCS Institute

To: The Board, Global Carbon Capture and Storage Institute Ltd(Insert or print name of Organisation)(Applicant)of(Insert or print address of Organisation)hereby applies to become a Member of the Global Carbon Capture and Storage Institute Ltd(Company).1. GuaranteeThe Applicant acknowledges that when it is admitted as a Member of the Company, it undertakes to pay AU$10 (as requiredunder clause 30(a) of the Company’s Constitution (Constitution)) in the event that the Company is wound up and does nothave adequate funds to discharge its debts and liabilities and the costs, charges and expenses of winding up.Option oneThe Applicant will supply AU$10 to the Company to hold on trust for the Applicant. The Applicantauthorises the application of the AU$10 by the Company only if the Applicant becomes a Member ofthe Company, the Company is wound up and the Company does not have adequate funds todischarge its debts and liabilities at the time it is wound up. The Applicant consents to the money notbeing invested and agrees that any interest earned on such sum is received by the Companyon its own account and may be applied by the Company in the carrying on of its business.Please note that the Global Carbon Capture and Storage Institute may invoice you for AU$10 if yourapplication for Membership is approved.Option twoThe Applicant will pay AU$10 at the time the Company is wound up, in the circumstances where theCompany does not have adequate funds to discharge its debts and liabilities.2. Applicant bound by the ConstitutionIf the Applicant becomes a Member of the Company, the Applicant agrees to be bound by the Constitution.3. Demonstration of a legitimate interest in the advancement of carbon capture and storage (CCS)The Global Carbon Capture and Storage Institute’s Board considers all applications for membership against criteria that willdemonstrate an Applicant’s legitimate interest in the advancement of CCS.Please address the following criteria (maximum 500 words against each criterion) and reference any attachments provided insupport of your application.(a) Description of organisationGLOBALCCSINSTITUTE.COM2

NOMINATION OF REPRESENTATIVETo: The Company Secretary, Global Carbon Capture and Storage Institute Ltd(Insert or print name of Organisation)(Applicant)of(Insert or print address of Organisation)hereby appoints the following Nominated Representative.All fields must be completedNamePosition titleRegistered street addressSuburbStatePostcodeCountryPhone Mobile FaxWebsiteEmailPursuant to clause 5(a)(i) (as amended from time to time) of the Global Carbon Capture and Storage Institute Ltd’s (Company)Constitution (Constitution) to act as the Member’s representative in any matters connected with the Company including aspermitted by the Australian Corporations Act 2001 (Cth)The Applicant acknowledges that under clause 5(b) of the Constitution, as amended from time to time,one Nominated Representative * is entitled to:(i) exercise at a general meeting (and any other Members’ meeting convened in accordance with the Constitution) all thepowers which the Member which appointed him or her could exercise if it were a natural person; and(ii) be counted towards a quorum on the basis that the Member is to be considered personally present at a generalmeeting (and any other Members’ meeting convened in accordance with the Company Constitution) by itsRepresentative.The following restrictions apply to the Representative’s powers (optional fi eld)Signature of Applicant’s authorised Representative(Insert or print signature)Name of Applicant’s authorised Representative(Insert or print name)* Members may appoint additional Representatives who areentitled to act in accordance with clause 5(b) in the absenceof the Nominated Representative.Date:_______________________________________________________________________(Insert or print date)SUBMIT YOUR FORM VIA:Mailing address:Membership, Global CCS InstituteEmail: membership@globalccsinstitute.com Fax: +61 (0)2 6162 1928GPO Box 828, Canberra ACT 2601 Australia To speak to a Membership Representative call: +61 (0)2 6175 5300GLOBALCCSINSTITUTE.COM4