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Online Application Form

Client data collection form

Instructions : Please read the following instructions before completing the form.

Option 1:
(Preferable for environmental policy): complete this online form, print out the last page titled
'authority to access information page'
Option 2:
When completing in a hard copy, please print, complete the whole form, and send it to:

Invest-Track
Suite 2, 668 Burwood Road,
Hawthorn East VIC 3123

Please select the account type: (You can select more than one account)

Individual/Joint A/c

Trust A/c

Company A/c

SMSF A/c

Personal details

Is this applicant a resident of Australia?

If no please provide your home country residence

Yes

Title

Given name

Middle name

Family name

Preferred name

Date of birth

Tax file number

Mobile

Home phone

Work phone

Fax

Email

Residential address

Suburb

State

Postcode

Is this address the mailing address?
(If no, please enter the mailing address below)

Yes

Mailing address

Suburb

State

Postcode

Are there more applicants to add?
If so, please provide the details when you reach page 6 of this online form

Bank Details

Note: Please provide the bank account details where the dividends and distributions will go into.

BSB

Account number

Bank name

Branch Name

Account Holder Name

Superannuation details

Superannuation name

Superannuation ABN

Superannuation TFN

Only enter the following information if you have selected SMSF a/c as the account type

How many trustees are there?

Is the above person one of the trustees?

Yes

If there is more than one trustee, please enter the following details

Trustee 1

Full name

Address

Suburb

State

Postcode

Trustee 2

Full name

Address

Suburb

State

Postcode

Company Trustee

Full name

Address

Suburb

State

Postcode

Superannuation Bank Details

BSB

Account number

Bank name

Branch Name

Account Holder Name

Account Operating Instructions

Please specify your account operating instructions

Anyone of us to sign

All of us to sign

Other

Company name

Company ABN

Company TFN

Note: Only complete this section if you have selected 'company' as the account type.

Registered Company Address

Suburb

State

Postcode

Is this the company mailing address?
(If no, please enter the mailing address below)

Yes

Mailing Address

Suburb

State

Postcode

Company Contacts

Title

Given name

Middle name

Family name

Work phone

Company contact address

Suburb

State

Postcode

Note: If this address is the same as the company's address above please leave it blank.

Email

Do you require two signatures

Yes

Company Details

Preferred Director Contact

Note:If the Director(s) contact details are the same as the above (under 'company contacts') leave it blank.

Director 1 contact details

Title

Given name

Middle name

Family name

Work phone

Address

Suburb

State

Postcode

Note: If this address is the same as the company's address in the 'company details' section please leave it blank.

Email

Director 2 contact details

Title

Given name

Middle name

Family name

Work phone

Address

Suburb

State

Postcode

Note: If this address is the same as the company's address in the 'company details' section please leave it blank.

Email

Company Bank Details

BSB

Account number

Bank name

Branch Name

Account Holder Name

Please note: the minimum amount to invest is $1000.00

Initial Investment

How much initial investment do you wish to put in? $

What is the method for the initial investment payment?

Cheque attached

Cheque to follow

Funds transfer via internet/phone banking

Direct debit

Funds transfer via authority to transfer

Do you user a margin lending provider?

Margin Lending

Yes

If yes please provide details below

Name of margin lender

Client number

Do you wish to Margin Lend?

Yes

If you choose yes, you will be elected into our
choice of Margin Lending provider.
Please ask us for more information on this.

Regular investment plan

Yes

This regular investment plan will be carried
out using the salary credit option

Note Any regular investment below $250 will be paid via salary credit.
Salary deduction or direct credit will be used for amount of $250 or more.

Repayment frequency

Weekly

Fortnightly

Monthly

Quarterly (min $750)

Amount

If the account details to be debited are the same as the bank account details that you have provided earlier,
then please leave the following blank

BSB

Account number

Bank name

Branch Name

Account Holder Name

Account details to be debited

Do you require a cheque book?

What size do you require?

Yes

100

Regular Investment

Stockbroker/Agent details

Stockbroker name

Stockbroker Company

HIN/SRN

If you have more than one Stockbroker/ Agent, please provide their details under the additional
information section on page 7.

Please add any additional applicants below

Applicant 2

Additional Information

Is this applicant a resident of Australia?

If no please provide your home country residence

Yes

Title

Given name

Middle name

Family name

Preferred name

Date of birth

Tax file number

Mobile

Work phone

Fax

Email

Residential address

Suburb

State

Postcode

Is this the mailing address?
(If no, please enter the mailing address below)

Yes

Mailing address

Suburb

State

Postcode

Applicant 3

Is this applicant a resident of Australia?

If no please provide your home country residence

Yes

Title

Given name

Middle name

Family name

Preferred name

Date of birth

Tax file number

Mobile

Work phone

Home Phone

Fax

Email

Residential address

Suburb

State

Postcode

Is this the mailing address?
(If no, please enter the mailing address below)

Yes

Mailing address

Suburb

State

Postcode

Additional info cont.

Additional stockbroker/agent 2

Stockbroker name

Stockbroker company

Stockbroker HIN/SRN

Additional stockbroker/agent 3

Stockbroker name

Stockbroker company

Stockbroker HIN/SRN

Additional financial institution details

BSB

Account number

Bank name

Branch Name

Account Holder Name

Authority to access information

NOTE: This authority to access information form must be printed, filled out, signed and mailed or faxed to the
following address/fax number.

Invest-Track
Suite 2, 668 Burwood Road, OR FAX: 03 9923 2713
Hawthorn East, VIC 3123

The remainder of the form can be submitted online by clicking the 'submit' button at the end of the page.

I/We authorise (Name)

of (Business name)

to access further information about my/our investment policies as may be required to fully understand such
investments and policies.

Client 1 name

as a trustee of

Address

Suburb

State

Postcode

Client 1 signature

Date

Client 2 name

as a trustee of

Address

Suburb

State

Postcode

Client 1 signature

Date

If you have login details for online services with your Share Registries, please kindly provide
them below in order to help us with the process of accessing your Investment Portfolios' historical information