OMR2_Beneficiary of an Individual Registration Form

Individual Shareholder Information
Shareholder Name *

First NameMiddle NameSurname
OMR2 Shareholder Registration No.*
Contact the office for the registration number for the Individual Shareholder.
Is the shareholder deceased?*
Beneficiary Details
Beneficiary Name*

First NameMiddle NameLast Name
Are you known by other names?*
Alternative Names*
Do you have a NZ Bank Account?*
Are you a NZ Resident?*
Gender*
IRD Number
Please enter like example 000-000-000
Date of Birth*

DayMonthYear
Current Date

DayMonthYear
Age
Type of Identification*
Upload ID type*

Upload document (as selected above)
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Beneficiary Contact Information
Postal Address*

Street Address/PO Box Number

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Postal Address*

Street Address/PO Box Number

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone (Day)
Mobile
E-mail Address
example@example.com
Your Bank Account Name*
Bank Account No.*
Please enter like example 00-0000-0000000-00
Upload Electronic Copy of Bank Verification*

Upload document to verify your bank account
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BSB Number*
Please enter like example 000000
Australian Bank Account No.*
Please enter like example 000000
Name of Bank *
Bank Branch Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Upload Electronic Copy of Bank Verification*

Upload document to verify your bank account
Cancelof

Declaration
Applicant Signature (Type Name)*
By signing this registration form you confirm that you have read and understood the notes below.
I am not a robot*
Date Signed*

DayMonthYear
Should be Empty:

Office Use