Account Application form


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account Application kit

May 2, 2016


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Account Application Kit
Blackwell Esteem Financials Pty Ltd

ACN 147 766 336 | AFSL 400364
Level 30, 35 Collins Street, Melbourne, VIC 3000

Tel: 1300 321 424 | +61 3 8689 9545 | Email: info@esteem-wealth.com

www.esteem-wealth.com


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Account Application form


CHECKLIST

1. Read and understood the Financial Services Guide.



2. Read and understood the Product Disclosure Statement.



3. Read and understood the Client Agreement.



4. Read and understood the Privacy Policy.



5. Completed and signed the Account Application Form.



6. Completed and signed the Risk Disclosure Statement.



7. Completed and signed the Client Acknowledgement and Declaration.



8. Completed and signed the Client’s Intermediary Authorisation and Standing Payment Instruction (where you have an intermediary or adviser).



9. Completed and signed the Excluded Offering/Sophisticated Investor Certificate (if applicable).



10. Completed and signed the Board/Trust Resolution (for Company and Trustee).



11. Completed and signed the Deed of Guarantee and Indemnity (for Company)



12. Completed and submitted the Identification Document (for all individuals).



iNSTRUCTION

  1. Pursuant to the requirement of the Australian Government, the Anti-Money Laundering and Counter-Terrorism Financing Act and the Australian Securities & Investments Commission, Blackwell Esteem Financials Pty Ltd is required to have a client FORMALLY IDENTIFIED before an account can be opened. All natural persons, who are either Account Holder, representatives of Account Holder, Authorized Persons of Account Holder or beneficial owners are required to provide a certified copy of identification document.

  2. Individual Account: Please complete this page along with section I, II and VI and VII

  3. Joint Account: Please complete this page along with section I, II, III, VI and VII

  4. Business Account: Please complete this page along with section I, IV, V, VI and VII

  5. Complete section VIII if you have an adviser.

  6. Complete section XI if you require an Accountant Certificate

  7. Complete section X if you are a Company

  8. Complete section XI if you are a Company or Trustee

account Information

Client/Account Type : Choose an item

Client/Account Name: Enter Full Name


Account Category : Choose an item.

If Wholesale, eligibility basis: Choose an item.

Others, please specify: Enter text

Product Value

Please note your minimum product value per trade must be more than $500,000

Accountant Certificate

Expiry Date: Date



Professional Investor:

Choose an item.

Others, please specify: Enter text.

Account Currency : AUD

Adviser/Promo Code: Enter text

Platform: Choose an item.

Preferred Portal User ID and Initial Password

User ID 1: Enter text

User ID 2: Enter text

User ID 3: Enter text




SECTION I

PERSONAL INFORMATION OF INDIVIDUAL/FIRST JOINT APPLICANT

PERSONAL Information

First Name: First Name

Middle Name: Middle Name

Last Name: Last Name

Date of birth: Date

Country of Tax residence:

Enter text




identification Information (provide at least one of the following)

Identification Type: Choose an item.

National ID Card No: National ID No

Medicare Card No: Medicare Card No

Driver’s licence No: Driver’s Licence No

Licence expiry date: Date

Passport No: Passport No


Country of Issue: Country

Passport Expiry Date: Date

contact information

Please select preferred contact 

 Office No: Office No

 Home No: Home No

 Mobile No: Mobile No

Email: Email

Residential Address:

Street: Street

City/Suburb: City/Suburb

State: State

Postal Code: Postal Code

Country: Country

Postal Address:  checked if same as residential address

Street: Street

City/Suburb: City/Suburb

State: State

Postal Code: Postal Code

Country: Country

Employment Information

Employment Status: Choose an item.

Employer: Employer

Occupation/Position: Occupation/Position

Industry: Industry

FINANCIAL information

Annual Income: Choose an item.

Approximate value of savings and investments: $ Enter Amount

Source of Income/Wealth: Choose an item.

Bank Details:

Bank Name: Bank Name

BSB/ABA/Other Code: BSB/ABA Code

SWIFT Code: Swift Code

Bank Address (including country): Bank Address

Account Name: Name as in bank account

Account Number/IBAN: Account No/IBAN

Account Currency: Account Currency

OTHER INFORMATION

Are you the Ultimate Beneficial Owner (“BO”)?: Yes

If No, please submit the PERSONAL INFORMATION (this form) of Ultimate BO.

Are you a Politically Exposed Person (“PEP”)? : No

If Yes, please provide details of or association to PEP. Please provide details of or association to PEP

SUPPORTING DOCUMENTS (Please submit certified true copies of one of each below)

Primary Identification Document: Choose an item.

Secondary Identification Document: Choose an item.
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