SCHEDULE 1- Registration Form
Part 1 – Account and Licence Details
☐ Monthly ☐ 6 Monthly ☐ Annual
| Box Size: ☐ Small ☐ Medium ☐ Large ☐ X-Large |
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| Commencement Date: _____/_____/_____________ |
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| Key Deposit Amount ($): | Number of keys issued: |
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Part 2 – Insurance Election
☐ Standard Insurance Included – $10,000
☐ Additional Insurance Requested
| Requested Insurance Amount (Maximum $1,000,000): |
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Part 3 – Customer Type
☐ Individual ☐ Individual as Sole Trader ☐ Individual as Trustee
☐ Company ☐ Company as Trustee ☐ Joint Holders ☐ Partnership
Part 4 – Intended Use of Facility
☐ Bullion ☐ Cash ☐ Jewellery ☐ Watches ☐ Documents ☐ Collectables
☐ Other, please specify: __________
☐ I acknowledge prohibited items must not be stored.
Part 5 – Customer/s Information
Customer 1 Full Legal Name: Date of Birth: Residential Address: Phone Number: Email Address: Occupation: ABN (if applicable): Name of Trust (if applicable): |
Customer 2 (if applicable) Full Legal Name: Date of Birth: Residential Address: Postal Address (if different): Phone Number: Email Address: Occupation: ABN (if applicable): Name of Trust (if applicable): |
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Part 6 – Entity Information (if applicable)
Trust Name: Trust Type: Trustee/s: Beneficial Owner/s: |
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Company Name: ACN: Director/s: Industry/Sector: Beneficial Owner/s: |
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Partnership Name: Partners: |
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Part 7 – Authorised Persons
Authorised Person 1: Full Legal Name: Date of Birth: Residential Address: Phone Number: Email Address: Relationship to Customer: |
Authorised Person 2: Full Legal Name: Date of Birth: Residential Address: Phone Number: Email Address: Relationship to Customer: |
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Part 8 – Next of Kin (if relevant)
Full Legal Name: Date of Birth: Residential Address: Phone Number: Email Address: Relationship to Customer: |
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Part 9 – AML/CTF Information
| Source of Funds: |
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Politically Exposed Person Declaration: ☐ Yes ☐ No
Part 10 – Verification of Identity
☐ Government Photo ID
☐ Proof of Address
☐ ASIC Extract (if applicable)
☐ Trust Deed (if applicable)
☐ Face-to-Face Verification Completed
☐ Electronic Verification Completed
Part 11 – Declaration and Signature
Customer/Authorised Representative 1 Name: Relationship to Customer (if relevant): Signature: |
Customer/Authorised Representative 2 Name: Relationship to Customer (if relevant): Signature: |
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| Date: | Date: |
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