QUEENSLAND TITLES REGISTRY	REQUEST TO AMALGAMATE	FORM 15 Version 4

Land Title Act 1994 and Water Act 2000	Page 1 of 1

Dealing Number	Lodger (Name, address, E-mail & phone number)	Lodger
OFFICE USE ONLY Privacy Statement Collection of information from this form is authorised by legislation and is used to maintain publicly searchable records. For more information see the Titles Queensland website.	Code
1. Lot on Plan Description of land held	Title Reference
2. Applicant
3. How land/shares in item 1 is held
4. Instrument by which land to be amalgamated was acquired Dealing Type Dated Dealing No. . Share acquired
5. Lot on Plan Description of land acquired	Title Reference
6. Amalgamated Lot on Plan description	Title Reference (if amalgamation of shares)
7. Request/Execution by applicant It is requested that: *The lots described in item 1 and item 5 be amalgamated and an indefeasible title be created for the land described in item 6. OR *The shares of the applicant specified in item 3 and item 4 be amalgamated and an indefeasible title be created for # for the land described in item 6. *delete if not applicable #state share and tenancy Witnessing officer must be aware of his/her obligations under section 162 of the Land Title Act 1994 signature full name qualification / / Witnessing Officer Execution Date Applicant's or Solicitor’s Signature (Witnessing officer must be in accordance with Schedule 1 Note: A Solicitor is required to print full name of Land Title Act 1994 eg Legal Practitioner, JP, C Dec) if signing on behalf of the Applicant