Financial Counselling Agency Authorisation Form April 2020

Financial counsellor
Authorisation Form
Purpose of the Authority form
By signing this authority, you authorise the financial counselling agency to act on your behalf with the named third party, such as a creditor, debt collector, external dispute resolution scheme or a telecommunications company.
When acting on your behalf, the financial counselling agency may (among other things):
- seek and exchange personal information about you and your account/s;
- negotiate; and
- enter into arrangements.
Authorisation
Third party:*
Reference no.:*
I/We:
Full Name (#1):*
Date of birth:*
MonthDayYear
Date
Address:*
Full Name (#2):
Date of birth:
MonthDayYear
Date
Address:
Your Business details (if applicable)
Business name:
ABN
Address:
Authorise:
Name of financial counselling agency (Authorised Representative):*
Financial counsellor’s name:*
Registration number:*
Address:*
Phone:*
Mobile:
Email:*
example@example.com
Signature
Name (#1):*
Clear
Date:*
MonthDayYear
Date
Name (#2):
Clear
Date:
MonthDayYear
Date
This form was developed by Financial Counselling Australia in consultation with industry, peak bodies and EDR schemes | April 2020
Should be Empty:

Financial counsellor