How to complete this form
Step 1The person being identified to complete and to sign this form
Step 2The following steps are ‘broker use only’. Sight the required identification documents (originals only)
Step 3Record the identification documents provided and verify that the person’s details match the identification documents. Certified copies of the identification documents must be provided to People’s Choice Credit Union
Step 4 Sign this form
Step 1 Applicant Details
Mr / Mrs / Ms / Miss / Other (please specify) / Member Number
Surname / First Name / Middle Name
Date of birth (DD/MM/YYYY)
/ / / / The applicant is male female
Contact Details
Work / Home / Mobile / Fax
Email Address
Current Residential Address of Applicant (must be an Australian residential address not a PO Box)
Unit number / Street number / Street name
Suburb / State / Postcode
Current Postal Address (if different to above)
Unit number / Street number / Street name
Suburb / State / Postcode
Withholding Tax
For taxation purposes aare you a resident of Australia? / No / Yes – please provide your TFN below
Foreign Tax
Are you a U.S. resident for tax purposes or a U.S. citizen? / No / Yes – please provide your U.S. Tax Identification Number below
For Tax purposes are you a resident of another country other than Australia and/or the U.S.? / No / Yes – please provide the country and Foreign Tax Identification Number below
My first country of residence for taxation purposes is
My second country of residence for taxation purposes is
TAX File Information
If not completed you may be taxed on any interest received.
This information will be destroyed once loaded on the People’s Choice Credit Union system
Australian TAX File Number or Exemption
Foreign Tax Identification Number/s or Exemption/s / Country applicable to
Country applicable to
Declaration
Annual Report
Every year Australian Central Credit Union Ltd trading as People’s Choice Credit Union (“People’s Choice Credit Union”) prepares an Annual Report which contains information on our financial position and performance, how efficiently we are being managed, and about any financial risks we may face. This report will be put up on the People’s Choice Credit Union website peopleschoicecu.com.au in October each year for your viewing.
DECLARATION BY APPLICANT
Your signature must be witnessed by the Broker.
I acknowledge that the information in this form is true and correct. The details in this form have been completed by me and not another person.
I apply for membership and one $2.00 share in People’s Choice Credit Union. I understand that if I have included $2.00 as payment towards my share in People’s Choice Credit Union and this results in having paid an excess for my share, then the difference will be refunded to me with 90 days. I agree to be bound by the rules of People’s Choice Credit Union.
I understand that it is an offence under the law including the Anti-Money Laundering and Counter-Terrorism Financing Act 2006 (Cth) (“AML-CTF Act”) to make a false and misleading statement. I declare that the details as shown on this form are complete and accurate.
I have received the Accounts & Access Facilities Terms & Conditions document, Fees & Charges document and Savings & Investments Interest Rates Brochure and agree to be bound by them.
I understand that where I am a resident of a country other than Australia for tax purposes, People’s Choice Credit Union may be legally obliged to pass on this informationand other information with respect to me and my accounts with People’s Choice Credit Union to the Australian Taxation Office (ATO) and that the ATO may then exchange this information with tax authorities of other jurisdictions pursuant to intergovernmental agreements to exchange financial account information.
I undertake to promptly notify People’s Choice Credit Union of any change in circumstances which affects my tax residency.
I understand the collection of Tax File Numbers or Exemption is authorised, and their use and disclosure are strictly regulated by tax laws and the Privacy Act 1988 (Cth). I understand that quotation of the number is not compulsory, but tax may be taken out of my interest if I do not quote my Tax File Number or claim an Exemption.
I have received a welcome pack which contains People’s Choice Credit Union’s Privacy Policy. I consent to the collection, use, handling, and disclosure of my personal information as set out in the Privacy Policy. I understand the Privacy Policy may change from time to time and will be kept updated of any changes to the Privacy Policy via People’s Choice Credit Union’s newsletters or on its website. I consent to the collection, use and disclosure of the information contained in this application and for any other application or communication I may have with People’s Choice Credit Union from time to time. If I supply information to People’s Choice Credit Union about another person, I confirm that I am authorised by that person to supply the information and I will inform that person how to contact People’s Choice Credit Union, how to obtain the Privacy Policy, that People’s Choice Credit Union will use and disclose their personal information for the purposes set out in this application and that they can gain access to that information.
I authorise People’s Choice Credit Union to provide its relevant service providers:
- Any information provided by me in this document (including personal information)
- Any other information I may provide to People’s Choice Credit Union which it may lawfully obtain about me where the provision of such information is required or allowed by law. This includes verification of personal information as required by the AML-CTF Act.
Signature / Date
Step 2 Sight the required identification documents
Sight current documents from the lists below. 1 x Category A, 1 x Category B +.1x Category C, 2 x Category B or 4 x Category C (explanation to be sought as to why a Category A or B is not available)
The documents must verify the following details as provided in Step 1:
- Applicant’s full name; and
- Residential Address or Date of Birth
Category (A) / Category (B) / Category (C)
- Drivers Licence
- Proof of Age Card/NSW Photo Card issued by a State or Territory government
- Passport
- Firearms licence
- Student ID card (with DOB)
- Indigenous community photo ID card
- Birth Certificate or Birth Extract
- A Citizenship Certificate
- Pension card
- Health care card
- Any other Government ID or licence with name and DOB, including photo IDs not in Category A
- Veterans Affairs concession card
- Australian Tax Office Tax Assessment Notice (issued in the last 12 months)
- Utility bills (issued within the last 3 months)
- Council rates (issued within the last 3 months)
- A bank statement (issued within the last 3 months)
- Electoral commission records
- Credit check
- Housing trust records
- Government notice recording financial benefits e.g. Centrelink (issued in the last 12 months)
Step 3 Verification Information
Record details of each identification document viewed
DOCUMENT 1 / DOCUMENT 2
Document Type
Document Number
Name on document
Address
Date of Birth
Issuer
Country Issued
Date Issued/Expired
DOCUMENT 3 / DOCUMENT 4
Document Type
Document Number
Name on document
Address
Date of Birth
Issuer
Country Issued
Date Issued/Expired
Step 4 Summary
Has verification been achieved? / Yes / No
Date Identification took place (DD/MM/YYYY) / / / /
By signing this form I confirm that I have interviewed the above mentioned Applicant face to face and sighted the original identification documents outlined above. I have provided People’s Choice with certified copies of the original identification documents sighted.
Signature of Broker
Name of Broker
Broker Number
Date (DD/MM/YYYY) / / / /
V1.4 0817-FRM 7.11.2
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