SECTION 2: DETAILS OF LICENCES & AGENCY AGREEMENTS PREVIOUSLY HELD *

Have you held an AFSL or Investment Advisers License?

YES NO

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Have you held an Insurance Broker's Licence?

YES NO

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Are you currently or have you been an Authorised Representative of an AFSL?

YES NO

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Is anyone in your practice, including directors, connected with an Australian Financial Services License (AFSL)?

YES NO

SECTION 3: EDUCATION, EXPERIENCE AND QUALIFICATIONS

Please list your educational qualifications and attach proof.

(Include schooling level, degrees, diplomas etc).

These will be listed on the ASIC website under your name once you become authorised.

View an example of a Statement of Attainment for RG146 HERE

NOTE: Attach proof of meeting RG146 requirements:

1) Provide advice in Superannuation

2) Provide advice in Self-Managed Superannuation Funds

3) Including CPD/CPE training register, where qualifications were completed more than 2 years ago.

Qualification *	Institution *	Year Completed *	Attach Proof *
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Please list your Financial Services Industry experience.

(Only applicable if you’ve provided advice under a licence in the past).

Date from	Date to	Employer	Position	Description

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Please list the professional bodies with whom you have a membership.

These will be listed on the ASIC website under your name once you become authorised.

Please attach proof below.

Date from	Date to	Professional Body	Membership Category	Attach Proof
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SECTION 4: GOOD FAME AND CHARACTER DETAILS

State whether in the last 10 years (All required):

(a)

You have been convicted of an offence in respect of conduct relating to the financial services industry;

YES NO

(b)

You have been discharged without conviction following an offence in respect of conduct relating to the financial services industry which was found proven by a court;

YES NO

(c)

You have been convicted of an offence in respect of dishonest conduct;

YES NO

(d)

You have been discharged without conviction following an offence in respect of dishonest conduct which was found proven by a court;

YES NO

(e)

You have had a pecuniary penalty or a civil penalty order imposed by a court, or tribunal, in respect of conduct relating to the financial services industry;

YES NO

(f)

You are currently or have ever been the subject of a criminal investigation or civil lawsuit;

YES NO

(g)

You are currently or have ever been the subject of an investigation that might see you viewed by ASIC as a person not fit to be granted authorisation under an Australian Financial Services Licence?

YES NO

(h)

You have a claim made or alleged negligence against you or any entity of which you were an associated person?

YES NO

NOTE: If you have answered Yes to any of the above, please provide further details as an attached document:

State whether you have ever been, or are currently bankrupt or insolvent.

YES NO

State whether you have ever been, or are currently associated with an insurance intermediary or securities licensee whose registration was refused, suspended or cancelled or who ceased trading.

YES NO

State whether you have ever been the subject of a banning order by ASIC, or have been a party to an enforceable undertaking.

YES NO

SECTION 5: COMPLAINTS HISTORY *

Have you ever had a complaint registered against you under a complaints resolution scheme within the last 5 years?

YES NO

Have you ever been the subject of a complaint within the financial services industry, irrespective of whether it was registered or not under a complaints resolution scheme?

YES NO

SECTION 6: DECLARATIONS AND UNDERTAKINGS

• I declare that the information provided by me in this application is true and correct to the best of my knowledge and belief.
• I undertake to advise the Licensee, for so long as I am an authorised representative of the Licensee, of any changes to the information provided by me in this application.
• I undertake to submit to all compliance and business reviews as required by the Licensee.
• I undertake to submit to all ongoing training and education as required by the Licensee.
• I undertake to surrender my authorised representative authority on request by the Licensee.
• I undertake to submit to all reasonable requests from the Licensee as required from time to time.

Please be advised that we have a 90 day application period, after which time your application will be automatically declined, you may be provided with the option to reapply – our re-application fee is $500 (exc. GST).
* This cost is subject to change, as determined by the SMSF Advisers Network.