Broker Accreditation Form

ACME Global
3147 Patterson Street, Houston, TX, 77002
info@acmecare.com
www.acmegcare.com
(123) 1234567
Broker Accreditation Form
Broker accreditation and transfer application
Application Type
Please choose the main purpose of your application.
New AccreditationTransfer of accreditationChange of detailsReactivationOther
Section 1 - Broker Personal Details
Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Phone Number
Email
example@example.com
Residential Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Section 2 - Broker Business Details
Business/Company Name
Business Number
Business/Company Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Section 3 - Licensing
Please select from the 3 options and provide details.
A director of an Australian Credit Licence (ACL) holderAn employee of an Australian Credit Licence (ACL) holderA credit representative of an Australian Credit Licence (ACL) holder
Broker’s credit representative Number (CRN):
Full Name of ACL Holder
ACL Number

Privacy Notice
Bank complies with the Australian Privacy Principles and Privacy Act 1988 (Cth) in collecting and managing your personal information. We are collecting your personal information for the purposes of assessing your application for broker accreditation, establishing and administering your appointment and our internal operations. Your personal information may be used and disclosed to third party service providers for these purposes. If you do not disclose this information, we will not be able to give you broker accreditation. We may also use your personal information to get in touch with you about Bank products and services, or those of our alliance partners, that may be of interest (unless you tell us not to) Bank’s Privacy and Credit Reporting Policy contains information about how you can request us to provide you access to or seek correction of any personal information we hold about you and how you may complain about a breach of an Australian Privacy Principle and how we will deal with such a complaint.
You may seek access at any time to personal information held by us about you and ask us to correct it if you believe it is incorrect or out of date. We may use your personal information to:

• Assess whether to accept your Broker Accreditation Application form,
• Administer and manage our relationship with you,
•Facilitate our internal business operations, including fulfilment of any legal requirements and confidential systems maintenance and testing,
• Inform you in your business capacity of products and services provided by us which we consider may be of value or interest to your clients unless you tell us not to.

We may disclose your personal information if it is necessary to do so in the following circumstances:

• To any regulatory body,
• To any credit reporting agency to obtain a commercial and/ or consumer credit report, trade reference or other commercial and/or consumer information about you to accept your Broker Accreditation Application form,
• To our external service providers that provide services for the purposes only of our business, on a confidential basis, for example advisers and mailing houses,
• To any persons acting on your behalf, including your solicitor or accountant, unless you tell us not to,
• To any party acquiring an interest in any business, and
• If you request us to do so or if you consent or where the law requires or permits us to do so.
Your authority to us
By signing this Broker Accreditation Application form you authorise us to collect, maintain, use and disclose your personal information in the manner set out in this privacy statement.

I consent to the Privacy Notice above.
Name
First NameLast Name
Date
MonthDayYear
Date
Signature
Clear

Aggregator Attestation
1) Aggregator legal name First Name Last Name of 1 ("The Aggregator") agrees to supply Bank with any information that Bank may request on an ongoing basis in order to confirm that any of our representatives meet Bank’s accreditation requirements (as may be amended from time to time)
2) The Aggregator confirms that we hold and are responsible for the following details of the broker identified in Section 2-3:
1. Australian Company Number / Australian Business Number and registration for goods and services tax (“GST”).
2. Registered address.
3. Contact details/names.
4. Confirmation we have verified the identity of each representative in accordance with the procedures for identifying individuals in the AML/CTF Act.
5. Industry start date.
6. Professional Memberships (i.e. MFAA)
7. AFCA Membership.
8. Industry related references.
9. Details about past history of each representative (as applicable) with respect to the following matters:
  1. Details on previous aggregator relationship (letter of separation);
  2. ACL cancellations;
  3. industry license cancellations;
  4. criminal convictions; and
  5. bankruptcy and insolvency
10. Professional Indemnity cover (“PI”) - the minimum level $2m (minimum cover).
11. Profiles of directors/major shareholder/senior non-executive management/brokers – including resume, identity check in accordance with AML/CTF Act requirements, Veda and police clearance.
12. Evidence of qualifications – minimum 12 months face to face experience writing regulated residential loans (unless Bank has agreed otherwise on an exception basis).
13. Evidence of knowledge of and compliance with the National Consumer Credit Protection Act (“NCCP”) and other relevant legislation.
3) The Aggregator acknowledges that:
1. Bank will spot check the information supplied and may ask for further detailed information to confirm its accuracy. Bank may conduct a more detailed audit if the information is found to be substantially deficient.
2. Bank reserves the right to accept/reject any representative listed at Bank’s absolute discretion.
4) The Aggregator attests that in relation to a representative listed who operate under their own ACL, that 2

A. has adequate processes in place to audit and manage these representatives on an ongoing basis; and
B. is responsible for the conduct of these representatives.
2) The Aggregator confirms that we hold and are responsible for the following details of the broker identified in Section 2-3:
1. Australian Company Number / Australian Business Number and registration for goods and services tax (“GST”).
2. Registered address.
3. Contact details/names.
4. Confirmation we have verified the identity of each representative in accordance with the procedures for identifying individuals in the AML/CTF Act.
5. Industry start date.
6. Professional Memberships (i.e. MFAA)
7. AFCA Membership.
8. Industry related references.
9. Details about past history of each representative (as applicable) with respect to the following matters:
  1. Details on previous aggregator relationship (letter of separation);
  2. ACL cancellations;
  3. industry license cancellations;
  4. criminal convictions; and
  5. bankruptcy and insolvency
10. Professional Indemnity cover (“PI”) - the minimum level $2m (minimum cover).
11. Profiles of directors/major shareholder/senior non-executive management/brokers – including resume, identity check in accordance with AML/CTF Act requirements, Veda and police clearance.
12. Evidence of qualifications – minimum 12 months face to face experience writing regulated residential loans (unless Bank has agreed otherwise on an exception basis).
13. Evidence of knowledge of and compliance with the National Consumer Credit Protection Act (“NCCP”) and other relevant legislation.
3) The Aggregator acknowledges that:
1. Bank will spot check the information supplied and may ask for further detailed information to confirm its accuracy. Bank may conduct a more detailed audit if the information is found to be substantially deficient.
2. Bank reserves the right to accept/reject any representative listed at Bank’s absolute discretion.
Authorized Representative Name:
First NameLast Name
Authorized Representative Signature
Clear
Should be Empty:

Broker Accreditation Form

Application Type

Section 1 - Broker Personal Details

Section 2 - Broker Business Details

Section 3 - Licensing

Privacy Notice

Aggregator Attestation