Apply to Become an Authorised Representative

Application for New Authorised Representative

Iconic Partners Pty Ltd | AFSL 450822 | ABN 37 167 051 470

Please complete this application form to apply to be appointed as an Authorised Representative of Iconic Partners.

Authorised Representative Application — Iconic Partners AFSL 450822

Personal Financial Product Advice

Limited Financial Product Advice

General Financial Product Advice

Other Areas of Interest

Title

First Name(s)

Surname

Date of Birth

Place of Birth

Home Address

Postal Address (if different)

Phone Number

Email Address

Business Name

ABN / ACN

GST Registered?

Business Address

Business Phone

Business Email

Your Position / Role

Do you wish to be authorised as:

Registered Business Name (if corporate)

Corporate ABN / ACN

Has ASIC previously issued you with an AR Number?

AR Number (if Yes)

Are you currently an AR of another AFS Licensee?

Current Licensee Name (if Yes)

Please confirm documents to be provided:

Account Name

Bank and Branch

BSB

Account Number

Account Name

BSB

Account Number

1. Have you been subject to proceedings relating to fraud, misrepresentation or dishonesty?

2. Have you been refused, banned or disqualified from any licensed profession?

3. Have you been suspended or disciplined by any professional body?

4. Are there outstanding debts with any insurer, fund manager or AFS Licensee?

5. Have you been subject to investigation by ASIC, ATO or APRA?

6. Have you ever been declared bankrupt or entered a Debt Agreement?

7. Have you been involved in management of any insolvent entity?

8. Have you ever been subject to a Professional Indemnity Claim?

9. Have you been subject to a complaint to an external Complaints Resolution body?

10. Have you been involved in management of any entity that had its licence revoked?

If YES to any of the above, please provide full details:

Full Name

Date

Declaration