Individual Membership Application

Individual Membership Application

This form is to be completed by every financial adviser and every director of the Financial Advice Provider (FAP) business that intends on joining KAN.
Personal Details
Which best describes your relationship with the FAP Business that is a member or prospective member of KAN?*

I am a financial adviser on behalf of the FAP Business.I am a financial adviser AND a director of the FAP Business.I am a non-advising director of the FAP Business.
Your name*

First NameMiddle NameLast Name
Preferred name (If applicable)
Email address*
example@example.com
Mobile phone number*
Date of Birth*

DayMonthYear
Are you a NZ Citizen?*

YesNo
Home address*

Street Address

Street Address Line 2

City

Postal / Zip Code
Your FSPR number
e.g. FSP999999. If you are in the process of applying for your FSP number, type "00000"
Dispute Resolution Scheme you belong to:
If you are new to industry and have yet to apply for DRS, put "TBC"
Legal company name of the business you will provide regulated financial advice on behalf of*
This will be the name of the business/FAP name that appears on the companies register and FSPR. e.g. not KAN, your branded business. If you are moving off an AB licence, put the future business/FAP name here
Are you a member of any industry bodies? (please specify):
For example FANZ

Privacy Waiver & Authority to Collect Information
I/We acknowledge and authorise that:
- Personal information provided to Kiwi Adviser Network Ltd (KAN) and its related or associated companies—whether contained in this application or obtained otherwise—may be collected, held, used, and disclosed for the following purposes:
  - To assess and make decisions on my/our application to join KAN as a Financial Advice Provider (FAP) or Financial Adviser (FA);
  - To conduct due diligence, including obtaining information from:
    
    Licensed product providers, insurers, and investment platforms;
    
    Previous or current aggregators, dealer groups, and compliance partners;
    
    The Financial Markets Authority (FMA) and other regulators;
    
    Current and/or former employers;
  - To verify details relating to conduct, complaints, compliance or disciplinary matters, production or performance history, and other information relevant to assessing my/our fitness and propriety;
  - To administer any agreements, products, or services I/we engage in with KAN;
  - To provide my/our contact details to third parties as necessary to process my/our application and support service delivery during the course of my/our agreement.
I/We authorise:
- KAN to obtain at any time from any person any information (including credit or criminal checks) relevant to this application and for that person to release such information to KAN;
- KAN to retain this information at its head office (23 Aviemore Drive, Highland Park) and/or any regional offices.
I/We understand:
- This waiver is provided under the Privacy Act 2020;
  Information will be used solely for the purposes of onboarding and managing the relationship with KAN;
- I/We have the right to request access to, and correction of, personal information held by KAN;
  This authority remains valid for the duration of the application and any resulting engagement, unless revoked by written notice.
I/We declare that:
- All information given in this application is true and wish to apply for an Adviser Agreement with KAN Ltd
- I/We the undersigned have read and understood this Privacy Act Waiver and Declaration.
Signature*

Applicant signature
Date*

DayMonthYear
Date
Type name in full*

First NameMiddle NameLast Name
Should be Empty:

Rows	Yes	No
Have you ever had an industry or business licence either refused, suspended, withdrawn, cancelled or subject to a banning order in New Zealand or overseas?
Except to the extent that any conviction is affected by the Criminal Records (Clean Slate) Act 2004, have you ever been convicted of an offence involving a criminal charge, or is any such charge pending?
Have you ever been a director of a company that has gone into voluntary liquidation or to a receiver, provisional liquidator, liquidator, scheme manager or an official manager has been appointed while you were a director or within six months that you ceased being a director?
Are you an undischarged bankrupt (in New Zealand or overseas) or have you been declared bankrupt?
Have you ever been refused membership of a statutory, professional or other body in no respect of your professional capacity in New Zealand or overseas?
Have you ever been subject to public disciplinary proceedings or expelled by a statutory body in respect of your professional capacity in New Zealand or overseas?
Have you ever been dismissed as an employee of a financial institution?
Have you any past of pending claims made against your Professional Indemnity Insurance under which you operate in relation to advice you have tendered?
Have you ever been refused Professional Indemnity Insurance?
Have you ever had a complaint upheld by, or have any current unresolved complaints lodged with an approved disputes resolution scheme?
Have you ever been denied membership or had your membership cancelled by a professional association?
Have you ever been denied accreditation or had your accreditation cancelled by a financial institution?
Have you ever been known by another name (maiden name or pseudonym)?
Are you, or any associated person in your business/company, including directors and employees involved in any way in property development or real estate sales?
Are you, or any associated person in your business/company, including directors and employees also acting as an accountant or solicitor?

Individual Membership Application

Personal Details

Advice Types & Education

Mortgage and Residential Lending

Personal and Business Risk Insurance

Investment and KiwiSaver Advice (Managed Funds)

Documents Required

Transferring Mortgage Adviser

New to Industry Mortgage Adviser Required Documents

Fit & Proper Adviser Declaration

Privacy Waiver & Authority to Collect Information