Additional GS1 Company
Prefix Allocation
Application Form – Effective 1 June 2017
Important Information
Note: To complete this form electronically, you must use Adobe Acrobat Reader. Download a free version at
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• This document forms part of the terms and conditions of the GS1 Australia Subscription Membership and Licence Agreement.
By applying for an additional GS1 Company Prefix Allocation you will be deemed to have read and understood these terms and
conditions. The current licence terms and conditions are available on our website www.gs1au.org
• Each application for an additional GS1 Company Prefix will incur an administration processing fee of $69.00 +GST.
Each additional GS1 Company Prefix supplied will incur an additional pro-rata annual fee as per schedule in Section 3.
• GS1 Australia encourages potential applicants to read our Privacy Policy and Terms of Trade readily available on our website,
www.gs1au.org
• Failure to complete this form in full, legibly, including all mandatory fields identified with *, will result in a processing delay.
Section 1: Company Details
GS1 Australia Account Number
*Company Name / Trading Name
Division of / Parent Company (If Applicable)
ABN/ACN Other Business Identifier
*Company / Head Office Street Address
*Suburb/City
*State/Country
*Postcode/Zip
Section 2: Contact Details
*GS1 Australia Coordinator / Primary Contact: Individual responsible for allocating GS1 Identification Keys within your company
Title (Ms/Mrs/Mr) and First Name Last Name
Position
Address (If different from Company)
Suburb/City
State/Country
Postcode/Zip
Email
Direct Phone
Mobile
GS1 Australia prides itself on the quality of our marketing material and will only send you information we believe to be relevant to
you. In accordance with the Australian Anti-Spam Legislation we respect that you may not want to receive this information. You
can unsubscribe from any direct marketing material at any time, by either unsubscribing from that communication or by doing so
in the Preference Management Centre, subject to that material not being considered essential to your role within the GS1 Australia
Subscription Membership.
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*Section 3: Schedule of Fees
Your Subscription Membership and Licence and the GS1 Company Prefix Allocation may be terminated if your account is not paid
annually or if you do not abide by the GS1 Australia Specifications and Guidelines.
Please select the allocation you wish to apply for and the month that you will apply in.
Fee Category
Additional Number Fee
Pro-rata annual fee for joining in month
Admin
Fee ($)
Annual
Fee ($)
Jul
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
 Small Allocation
69.00
310.00
310.00
284.17
258.33
232.50
206.67
180.83
155.00
129.17
103.33
77.50
51.67
25.83
 Large Allocation
69.00
930.00
930.00
852.50
775.00
697.50
620.00
542.50
465.00
387.50
310.00
232.50
155.00
77.50
Allocation
(10,000 GTINS)
(100,000 GTINs)
GS1 numbers are initially allocated as follows:
< $50M Turnover will be assigned an 8 digit GS1 Company Prefix giving you
10,000 GTINs and other GS1 Identification Keys
Calculate Your Fees Payable
Admin Fee ($)
> $50M Turnover will be assigned a 7 digit GS1 Company Prefix giving you
100,000 GTINs and other GS1 Identification Keys
Plus Pro-Rata Fee ($)
Additional Number ranges can be allocated to you on request at any time,
and after payment of applicable fees.
10% GST ($)
69.00
Sub Total ($)
TOTAL
*Section 4: Payment Methods
We provide a number of payment options for your subscription membership. Please choose your preferred payment option below:
FF Option A: Direct Debit Payment
• Download the Direct Debit form from our website www.gs1au.org and provide with this application form
• Direct Debit discounts will not apply to this initial transaction, but will be applicable on all other transactions where the Direct
Debit is set up to debit a nominated Bank Account
• Direct Debit via a nominated Credit Card will not attract the standard direct debit discount, however Credit Card processing
fees will not be applied
FF Option B: Credit Card Payment
• A credit card processing fee applies when paying by credit card (VISA 1.5%, MASTERCARD 1.5%, AMEX 2.6%). These fees will
be applied by GS1 Australia when processing payment.
• If you wish to make a credit card payment over the phone, please call 1300 227 263
Visa
Mastercard
American Express
Card Holder's Name
Card Number
Expiry Date
Signature
Date
FF Option C: EFT Payment
• Please email your application along with a Remittance Advice to [email protected] or fax to +61 3 9558 9551
• GS1 Australia Bank Details
Bank National Australia Bank
Account Name GS1 Australia Ltd.
BSB No. 083 266
Account No. 69615 7718
FF Option D: Cheque Payment
• Please provide your cheque number
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*Section 5: Signature Approval
Your GS1 Company Prefix and initial issued GTIN range will be sent to you upon receipt of your completed application form and
payment of appropriate fees. The GS1 Company Prefix allocated to your company is exclusively for your use - you must not
assign, licence or allow its use by any other company.
I/ We­­­­________________________________________________ declare that I/We have read, understand and shall abide by the
Terms and Conditions as set out in my GS1 Australia Subscription Membership and Licence Agreement and/or the Terms and
Conditions available from the GS1 Australia website www.gs1au.org; and that the information provided by me as the applicant,
and in any accompanying documents, is true and correct in every detail, and that when I no longer require these numbers, I will
advise GS1 Australia in order for their issue to be cancelled.
Full Name (Director/Company Official)Position
Signature
Date
Download instructions for signing forms
Please return the completed form with payment to GS1 Australia.
GS1 Australia
Head Office, 8 Nexus Court, Mulgrave VIC 3170
Locked Bag 2, Mt Waverley VIC 3149
T 1300 227 263 I E [email protected]
www.gs1au.org
CONNECT WITH US
I
F +61 3 9558 9551
I
ABN 67 005 529 920
GS1 is a registered trademark of GS1 AISBL.
1754_0517
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