Client Identity Verification Form

Client Identity Verification
Business Details

ABNTFNRegistered Business Name
Entity Type*
Pty Ltd, Trust etc
Office Holder Name*

Given NameSurnamePosition
Date of Birth*

MonthDayYear
Date
Director ID Number
Mandatory for all Directors of Pty Ltd
Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Postal Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
E-mail*
example@example.com
Identification Documents Required;

1 Primary (Photo) Document
- Drivers License
- Proof of Age Card
- Passport/Immicard
or

1 Primary (Non-Photo)
- Birth Certificate
- Government Pension Card
- ASIC Company Statement
and 1 Secondary Document
- Medicare Card
- ATO Notice
- Council Rates
- Student Card
- Letter of Authority
Where the Authorised Person for a Company is not the Director, a letter signed by the Directors authorising them to act must be provided.

A letter of authority to act which is signed by at least 2 members of the Committee must be provided for all Other Incorporated Entities
Upload Primary ID*

Drivers Licence/Passport/Proof of Age Card
Cancelof
Upload Secondary Document

Company/Other- Letter of Authority
Cancelof
Yes, I doNo, I don't
Other Authorised Representative

First NameLast Name
Yes, I doNo, I don't
Signature

Clear
Should be Empty: