Application Form Entity

1Entity Information

2Entity Ownership and Control Structure

3FATCA Status and CRS Declaration

4Acknowledgement

5Identity Verification of New Applicant

6Additional Information

Thank you for choosing Collinson Forex Limited (“CFX”). This Account Application Form must be read together with our Terms and Conditions on our website. If we accept your application for an Account, the agreement between us and you (the “Account Holder”) will comprise this Account Application Form and the Terms and Conditions (“Agreement”).
1. Entity Details
Full name of the business*
Phone Number*
Registration / Incorporation number*
Business Physical Address*
Address City ZIP / Postal Code Country
Tax Number
Email*
2. Nature and Purpose
Nature of Business
a) What industry is your organisation in?*

i.e. Construction, import/export, commercial property investment etc.
b. What does your organisation do in the above industry?*

i.e. Health food export, wine wholesaler, cosmetics import etc.

c. List of countries normally dealing/trading with*

Account Behaviour Baseline
a) Approx. number of annual transactions*

e) Source of funds/wealth*

e.g. Business revenue; sale of company assets; product trading revenue; shareholder capital injection

Approx. annual trade volume (NZD)

f) Purpose of transactions*

e.g. Paying suppliers in Germany; repatriating overseas sales revenue back to NZ; purchasing stock from NZ supplier

Approx. frequency of transactions
Approx. number of transactions per frequency
d) Approx. average transaction volume (in NZD)
i.e. the average size of transactions
Products and Services Required
- Spot Foreign Exchange
- Forward Foreign Exchange*
*For Forward Foreign Exchange - you will need to provide either a Large Wholesale Investor Certificate or an Eligible Investor Certificate depending on your classification. Please kindly contact us for the criteria.

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Does your entity have any nominee directors and/or shareholders and/or nominee general partners?
- Yes
- No
Directors, Shareholders (with more than 25% shareholding), and Authorized persons, Trustees
Is any trust a beneficial owner (enjoys the benefits of ownership or effective control) of your company?
- Yes
- No
If you have answered Yes, please provide the page of the trust deed where all trustees are listed, and IDs and proof of address of the listed trustees.
Choose
- Authorised person
- Directors
- 25% and 25% + shareholders
- Partner
- Nominee Director
- Nominee Shareholder
- Nominee General Partner
- Trustee
Director #1
Name
Given Name(s) Surname
Other names and aliases
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address (No Po Box)
Adress City ZIP / Postal Code Country
Home Phone
Mobile
Email
Director #2
Name
Given Name(s) Surname
Other names and aliases
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address (No Po Box)
Adress City ZIP / Postal Code Country
Home Phone
Mobile
Email
Director #3
Name
Given Name(s) Surname
Other names and aliases
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address (No Po Box)
Adress City ZIP / Postal Code Country
Home Phone
Mobile
Email
Director #4
Name
Given Name(s) Surname
Other names and aliases
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address (No Po Box)
Adress City ZIP / Postal Code Country
Home Phone
Mobile
Email
25% and 25% + Shareholders #1 (if not a Director)
Name
Given Name(s) Surname
Other names and aliases
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address (No Po Box)
Adress City ZIP / Postal Code Country
Home Phone
Mobile
Email
25% and 25% + Shareholders #2 (if not a Director)
Name
Given Name(s) Surname
Other names and aliases
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address (No Po Box)
Adress City ZIP / Postal Code Country
Home Phone
Mobile
Email
25% and 25% + Shareholders #3 (if not a Director)
Name
Given Name(s) Surname
Other names and aliases
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address (No Po Box)
Adress City ZIP / Postal Code Country
Home Phone
Mobile
Email
25% and 25% + Shareholders #4 (if not a Director)
Name
Given Name(s) Surname
Other names and aliases
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address (No Po Box)
Adress City ZIP / Postal Code Country
Home Phone
Mobile
Email
Authorized Person Details
Name
Given Name(s) Surname
Other names and aliases
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Address and Contact Details
Residential Address (No Po Box)
Adress City ZIP / Postal Code Country
Home Phone
Mobile
Email
Partner # 1
Name
Given Name(s) Surname
Other names and aliases
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address
Address Address Line 2 City State / Province / Region Postcode Country
Mobile
Email
Partner #2
Name
Given Name(s) Surname
Other names and aliase
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address
Address Address Line 2 City State / Province / Region Postcode Country
Mobile
Email
Partner #3
Name
Given Name(s) Surname
Other names and aliase
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address
Address Address Line 2 City State / Province / Region Postcode Country
Mobile
Email
Partner #4
Name
Given Name(s) Surname
Other names and aliase
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address
Address Address Line 2 City State / Province / Region Postcode Country
Mobile
Email
Nominee Director #1
Name
Given Name(s) Surname
Other names and aliase
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address
Address Address Line 2 City State / Province / Region Postcode Country
Mobile
Email
Nominee Director #2
Name
Given Name(s) Surname
Other names and aliase
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address
Address Address Line 2 City State / Province / Region Postcode Country
Mobile
Email
Nominee Director #3
Name
Given Name(s) Surname
Other names and aliase
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address
Address Address Line 2 City State / Province / Region Postcode Country
Mobile
Email
Nominee Director #4
Name
Given Name(s) Surname
Other names and aliase
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address
Address Address Line 2 City State / Province / Region Postcode Country
Mobile
Email
Nominee Shareholder #1
Name
Given Name(s) Surname
Other names and aliase
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address
Address Address Line 2 City State / Province / Region Postcode Country
Mobile
Email
Nominee Shareholder #2
Name
Given Name(s) Surname
Other names and aliase
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address
Address Address Line 2 City State / Province / Region Postcode Country
Mobile
Email
Nominee Shareholder #3
Name
Given Name(s) Surname
Other names and aliase
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address
Address Address Line 2 City State / Province / Region Postcode Country
Mobile
Email
Nominee Shareholder #4
Name
Given Name(s) Surname
Other names and aliase
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address
Address Address Line 2 City State / Province / Region Postcode Country
Mobile
Email
Nominee General Partner #1
Name
Given Name(s) Surname
Other names and aliase
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address
Address Address Line 2 City State / Province / Region Postcode Country
Mobile
Email
Nominee General Partner #2
Name
Given Name(s) Surname
Other names and aliase
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address
Address Address Line 2 City State / Province / Region Postcode Country
Mobile
Email
Nominee General Partner #3
Name
Given Name(s) Surname
Other names and aliase
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address
Address Address Line 2 City State / Province / Region Postcode Country
Mobile
Email
Nominee General Partner #4
Name
Given Name(s) Surname
Other names and aliase
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address
Address Address Line 2 City State / Province / Region Postcode Country
Mobile
Email
Trustee #1
Name
Given Name(s) Surname
Other names and aliase
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address
Address Address Line 2 City State / Province / Region Postcode Country
Mobile
Email
Trustee #2
Name
Given Name(s) Surname
Other names and aliase
Gender
Date of Birth
DD slash MM slash YYYY
Place of Birth
Nationality
Residential Address
Address Address Line 2 City State / Province / Region Postcode Country
Mobile
Email

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1. Tax Residence
Is the Entity a tax resident of another country (other than New Zealand)?*
- Yes * If yes, please list all your other countries of tax residency.
- No (go to the next section)
* If you are a US person, please also fill out Form W-9 or submit a self-declaration of FATCA status. You may also wish to visit the IRS website to determine if you need to complete and submit any additional IRS forms.

The term ‘US person’ means:
- US citizens, including those resident outside the United States
- US permanent residents, including green card holders
- People born outside the US with a US parent
- US tax residents
- Certain persons who spend a significant number of days in the United States each year
- Corporations, estates and trusts, and other entities controlled by US persons

Country of Tax Residence	Tax Number (or equivalent)	Not available	Please provide an explanation if Tax Number is not available

2. Entity Classification
Please provide the status of the Entity (refer to below for Definition of Terms for Entity Classification):
Active Non-Financial Entity (ANFE): a likely status for entities that derive the majority of their income, within a reporting period, through the course of an active trade or business (for example: retail or service-based business).

Passive Non-Financial Entity (PNFE): main source of income is passive (for example: your entity has ≥ 50% passive income AND ≥ 50% passive income generating assets (in the previous reporting period).

Financial Institution (FI):a Custodian Institution, Depository Institution, Investment Entity, or Specified Insurance Company. Apart from more obvious entities such as banks, this can also include non-bank deposit takers, collective investment entities, mutual funds, private equity funds, hedge funds, investment managers and advisors, and certain brokers and trusts (including some managed family trusts).

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Acknowledgement*
I agree to the acknowledgement
1. Electronic Verification

To meet the requirements under the Anti-Money Laundering and Countering Financing of Terrorism Act 2009 (AML/CFT Act), we must verify our client’s identity and residential address.

One option is to try and do this electronically, however not everyone can be verified electronically, please be advised that we may still contact you for further verification if the electronic verification fails.

As part of the electronic verification processes, your personal details are disclosed to and matched with information held by the issuer of the identity document containing your personal details e.g. your drivers’ licence or the official record holder of your information, via third party systems.

We will only use your personal details for the purpose of verification under the AML/CFT Act.

By signing this form, you agree to verify your identity and address electronically against government related identifiers and other authoritative data sources.

2. Anti-Money Laundering and Countering Financing of Terrorism Act 2009

I/We acknowledge that the CFX is subject to anti-money laundering and countering the financing of terrorism laws (AML/CFT laws) in New Zealand. This may include reporting of suspicious transactions required by AML/CFT laws to the Commissioner of the New Zealand Police.

I/We acknowledge that the CFX may use a third party system to verify my identity to determine whether I am/we are recorded with any notation as Politically Exposed Persons and whether I/we have a criminal record.

I/We agree to provide CFX (and its employees, agents, nominees and related entities) with reliable information and other assistance it reasonably requires to establish the bona fides of the source of my/our funds/wealth, and to comply with the AML/CFT laws.

I/We represent and warrant that I/we have no cause to believe the funds used to FX trades are the proceeds of crime or will be used to finance terrorism.

I/We agree to indemnify CFX (and its employees, agents, nominees and related entities) against any loss it suffers as a result of me/us providing incorrect or incomplete information.

I/We understand that failure to comply with the reasonable request for information by the CFX to satisfy AML/CFT laws will result in my/our application being rejected.

3. Personal Information and Privacy Act

I/We consent and agree that all information about me/us disclosed in this form may be used by CFX (and its employees, agents, nominees and related entities) or disclosed to and used for the purpose of completing/monitoring the transactions, including disclosure to the Financial Markets Authority and in compliance with the AML/CFT laws.

I/We know that CFX may use the information on this form for the purpose of:
1. Creating and maintaining risk related models, including but not limited to risk assessment, risk analysis and risk management;
2. Fulfilling reporting obligations, including but not limited to Annual AML/CFT Report, STR, PTR, CRS, FATCA and any other reporting obligations imposed by New Zealand laws and regulations;
3. Responding to bank inquires;
4. Marketing products, services and other subjects under the umbrella of Collinson & Co;
5. Meeting the requirements to make disclosure under the requirements of any law binding on us or under and for the purpose of any guidelines issued by regulatory or other authorities to comply;
6. Any other purposes relating to the purposes listed above.
I/We know that I/we can request such access to and correction of any information held about me/us by CFX.

Notwithstanding the foregoing, I/we acknowledge that where a suspicious transaction report has been made about me/us, the person who has made that report is not able to give me/us access to any information about that report (including its existence) and I/we have no right to request information in that report to be corrected.

I/We will inform CFX of any changes to the information provided by me/us to CFX.

4. United Stated (US) Foreign Account Tax Compliance Act (FATCA) Automatic Exchange of Information (AEOI) and the Common Reporting Standard (CRS)

I/We acknowledge that CFX has certain obligations to report information held about me/us under FATCA and CRS and I/we consent to CFX (and its employees, agents, nominees and related entities) disclosing all such information to the necessary parties.

I/We acknowledge that I have examined the information provided and it is true, correct, and complete to the best of my/our knowledge
and belief.

I/We understand and agree that on specific request from any relevant tax authorities or any party authorized to audit or conduct a similar control for tax purposes, the information contained in this section and/or a copy of this form can be disclosed to such tax authorities or
such party.

In case of any change in circumstances that causes the information contained herein to become incorrect I/we recognize that I/we will
have to provide a suitable updated declaration within 30 days of such change in circumstances.
Please be advised that penalties under the AEOI laws may apply if you provide false or misleading information, fail to provide this information, or fail to provide an update if there is a material change to the information you have provided. This includes civil penalties of $1,000 per offense that Inland Revenue can apply. Substantial criminal penalties can be applied by the courts for knowledge-based offenses. These penalties apply for the purposes of both FATCA and CRS.
Terms and Conditions*
I agree to the Terms and Conditions
Click Here to read Terms and Conditions
Declaration and Signature
By signing this form, I agree and confirm that:
- - My answers above are correct.
- - I will promptly send notification should my answer in any category above changes in the future.
Hidden
Declaration and Signature
By signing this form, I agree and confirm that: -My answers above are correct. -I will promptly send notification should my answer in any category above changes in the future.
Date*
Signed on behalf of the Organisation by:
Full Legal Name of Director/Authorised Signatory*
Signature*
Option to upload digital signature
Max. file size: 100 MB.
Full Legal Name of Director/Authorised Signatory
Signature
Full Legal Name of Director/Authorised Signatory
Signature
Full Legal Name of Director/Authorised Signatory
Signature
Full Legal Name of Director/Authorised Signatory
Signature
Full Legal Name of Director/Authorised Signatory
Signature

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Proof of Identification and Residential Address (Apply to Applicant, Authorized Person, Director, 25% + Shareholder and Trustee)
To confirm Name and Date of Birth
Current passport (including the signature page)
File*
Drop files here or

Max. file size: 100 MB.
To confirm Residential Address
A bank statement issued by a registered bank to the individual that is not more than 3 months old showing the address of the individual
File*
Drop files here or

Max. file size: 100 MB.

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Application Form Entity

1. Entity Details

2. Nature and Purpose

Nature of Business

Account Behaviour Baseline

Products and Services Required

Directors, Shareholders (with more than 25% shareholding), and Authorized persons, Trustees

Director #1

Director #2

Director #3

Director #4

25% and 25% + Shareholders #1 (if not a Director)

25% and 25% + Shareholders #2 (if not a Director)

25% and 25% + Shareholders #3 (if not a Director)

25% and 25% + Shareholders #4 (if not a Director)

Authorized Person Details

Address and Contact Details

Partner # 1

Partner #2

Partner #3

Partner #4

Nominee Director #1

Nominee Director #2

Nominee Director #3

Nominee Director #4

Nominee Shareholder #1

Nominee Shareholder #2

Nominee Shareholder #3

Nominee Shareholder #4

Nominee General Partner #1

Nominee General Partner #2

Nominee General Partner #3

Nominee General Partner #4

Trustee #1

Trustee #2

1. Tax Residence

2. Entity Classification

1. Electronic Verification

2. Anti-Money Laundering and Countering Financing of Terrorism Act 2009

3. Personal Information and Privacy Act

4. United Stated (US) Foreign Account Tax Compliance Act (FATCA) Automatic Exchange of Information (AEOI) and the Common Reporting Standard (CRS)

Declaration and Signature

Proof of Identification and Residential Address (Apply to Applicant, Authorized Person, Director, 25% + Shareholder and Trustee)

To confirm Name and Date of Birth

To confirm Residential Address

Entity Classification - Tax Residence of Controlling Persons

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