Application Form

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Applicant

[date* date id:x_date]

[date* birthdate id:x_birthdate]

Are you a member of a professional accounting body?
 Yes No

Have you previously been authorised to provide services under an Australian Financial Services Licence?
 Yes No

Preferred method of payment

Annual Monthly 

Licences, Authorisation

Within the last 10 years, within Australia and/or overseas, have you ever been refused the right, or been restricted in the right, to carry on any trade, business or profession for which an authorisation (licence, certificate, registration or other authority) is required by law?

 Yes No

Within the last 10 years, within Australia and/or overseas, have you ever been subject to disciplinary action in relation to any such authorisation?

 Yes No

Within the last 10 years, within Australia and/or overseas, have you ever been the subject of any investigations or proceedings that are current or pending and which may result in disciplinary action being taken in relation to any such authorisation?

 Yes No

Within the last 10 years, within Australia and/or overseas, have you ever been engaged in the management of any companies/businesses that have had a Corporations Act 2001 (or previous corresponding laws) licence cancelled?

 Yes No
Professional Memberships, Accreditation and Indemnity Insurance

Within the last 10 years, within Australia and/or overseas, have you ever been reprimanded, or disqualified or removed, by a professional or regulatory body or external dispute resolution scheme in relation to matters relating to your honesty, integrity or business conduct?

 Yes No

Within the last 10 years, within Australia and/or overseas, have you ever had any past, present or pending claim made against a Professional Indemnity Insurance Policy in relation to advice you have tendered?

 Yes No

Within the last 10 years, within Australia and/or overseas, have you ever been refused Professional Indemnity Insurance?

 Yes No

Within the last 10 years, within Australia and/or overseas, have you ever had your authorised representative status cancelled or suspended by an AFS licensee?

 Yes No
Names

Within the last 10 years, within Australia and/or overseas, have you ever carried on business under any name other than the name or names shown in this application?

If YES, please provide name:

 Yes No

Within the last 10 years, within Australia and/or overseas, have you ever been known by any name other than the name or names shown in this application?

 Yes No
Offences

Within the last 10 years, within Australia and/or overseas, have you ever been the subject of administrative, civil or criminal proceedings or enforcement action, which were determined adversely to you (including by you consenting to an order or direction, or giving an undertaking not to engage in unlawful or improper conduct) in any country?

 Yes No
Solvency

Within the last 10 years, within Australia and/or overseas, have you ever been declared bankrupt or insolvent under administration, or is there any such action pending?

 Yes No

Within the last 10 years, within Australia and/or overseas, have you ever been engaged in the management of any companies/businesses that have had an external
administrator appointed, or which have entered into a compromise, or scheme of
arrangement, with its creditors?

 Yes No

Within the last 10 years, within Australia and/or overseas, have you ever been engaged in the management of any companies/businesses that were declared insolvent?

 Yes No

Within the last 10 years, within Australia and/or overseas, have you ever been engaged in the management of any companies/businesses that were declared the equivalent of insolvent under the law of an external territory or country other than Australia?

 Yes No