This Application Should Be Completed by Applicants Seeking to Become an NZDX Advisor

NZX PARTICIPANT RULES

APPLICATION

This application should be completed by applicants seeking to become an NZDX Advisor

Please return this application form and supporting documentation to:

NZX Regulation

NZX Limited

P O Box 2959

WELLINGTON

It is essential that you read this application form in conjunction with the NZX Participant Rules.

CONFIDENTIALITY

NZX will keep confidential all information provided to it by the Applicant in relation to its application, except to the extent that disclosure of any or all of the information is necessary for the exercise of its regulatory functions, or as otherwise required by law.

INSTRUCTIONS

Applicants must submit the application form (to be completed in type written form with original signatures included) along with supporting documentation or information (as outlined in the NZX Participant Rules ). Supporting documentation should besupplied in typed format, in as much detail as the applicant feels appropriate to support their application, but in any event to satisfy the criteria contained in the NZX Participant Rules.

Please note that NZX may require additional information in relation to the application form or any of the supporting documentation filed in support of the application.

NZX reserves the right to decline an application notwithstanding that an Applicant meets the minimum criteria set out in the NZX Participant Rules.

APPLICANT DETAILS

1.Name, Residential Address and Telephone Number of Applicant:
2.NZX Firm or Bank Only Participant employing or contracting the Applicant and contact details:
3.Details of the Applicant’s work experience and expertise (including details of where and with whom that experience was obtained) which qualifies the Applicant to become an NZDX Advisor:
4.Details of Applicant’s professional and educational tertiary qualifications in the field of finance, economics, accounting or any other tertiary qualification directly related to the Securities Market or details of grades obtained in those examinations prescribed by NZX in lieu of tertiary qualifications:
5.Details of Applicant’s on the job training (which training must be for a minimum of 6 months) and details of the person, including that person’s contact details, from whom that training was received:

SUPPORTING DOCUMENTATION / INFORMATION – to be attached to the application:

(Please ensure all applicable and relevant supporting documents are attached to this Application. Please have regard to the assessment criteria outlined in the NZX Participant Rules, applicable to designation as anNZDX Advisor when compiling this supporting documentation).

Written confirmation from Managing Principal or Responsible Executive (as applicable) for organization that employs or contracts the Applicant that that person supports the Applicant’s application;

Evidence (by way of reference or testimonial) to support the employment history and experience detailed in the application (if requested by NZX);

Evidence of qualifications and examination results;

Details of any dispute the Applicant may have had with any entity with whom he or she has previously been employed or contracted;

Details of any adverse or potentially adverse matters in respect of the Applicant which have been brought to the attention of any relevant regulatory authorities during the last 6 years (where possible please provide copies of any relevant correspondence in relation to such matters);

Copy of Applicant’s sharebrokers licence (if required to have one by law);

Declarations as required by the NZX Participant Rules in support of the application (responsible Executive or Managing Principal and Applicant);

Any other information which the Applicant thinks may be relevant to NZX in considering this application.

DECLARATION BY APPLICANT TO NZX

(“the Applicant”) hereby declares that:

All the information contained in this application form and otherwise supplied is complete, true, accurate and not misleading.
I have read the NZX Participant Rules and believe that this application conforms to the criteria (except as specifically notified to you with this application) for designation as an NZDX Advisorset out in those rules.
I have not been subject to any disciplinary action by a regulator or law enforcement agency in the context of financial services or corporate finance and save as set out in this application, have not been disqualified by a court from acting as a director of any company or from acting in the management or conduct of its affairs.

Signature of Applicant:

Date:

Once completed this application form should be posted to:

NZX Regulation

NZX Limited

PO Box 2959

WELLINGTON

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