Account Application Form – Individual & Sole Trader

Thank you for choosing Direct FX Limited (“DFX”). 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”).

Section A: Account Information

1. Personal Details

Given name*

Surname*

Other names and aliases

Gender*
MaleFemale

Date of Birth (DD/MM/YYYY)*

Place of Birth*

Nationality*

Mobile number*

Residential Address*

City*

Country*

Postcode*

Email*

2. Employment or Business Details

Employer / Trading Name

Registration / Incorporation number

Job Title

Business phone number

Business Physical Address

City

Country

Postcode

Email

3. Nature and Purpose

Account Behaviour Baseline

a) Approx. number of annual transactions*

b) Approx. annual trade volume (in NZD)*

c) Approx. number & frequency of transactions I.e. 5 weekly / 3 monthly / 2 quarterly*

d) Approx. average transaction volume (in NZD)*

e) Source of funds/wealth E.g. Business revenue; sale of company assets; product trading revenue; shareholder capital injection*

f) Purpose of transactions E.g. Paying suppliers in Germany; repatriating overseas sales revenue back to NZ; purchasing stock from NZ supplier*

g) List of countries normally dealing/trading with*

Section B: Account Ownership and Control

Authorised persons

Section C: Foreign Account Tax Compliance Act (FATCA) and Common Reporting Standard (CRS) Declaration

1. Tax Residence

Is the Individual (not entity) a tax resident of another country?
Yes (please list all other countries of tax residency)No (go to the section D)

If you are a US person, please complete 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 US

• US permanent residents, including green card holders

• US tax residents

• People born outside the US with a US parent

• Certain persons who spend a significant number of days in the US each year

• Corporations, estates and trusts, and other entities controlled by US persons

Section D: Politically Exposed Person (PEP) Self-certification

Under Anti-Money Laundering and Countering Financing of Terrorism Act 2009, Financial Institutions have an obligation to check whether a client is a Politically Exposed Person (PEP). Please read definitions below carefully, answer "Yes" or "No" in each case.

Positions

Do you, or an immediate family member*, hold (or held at any time in the last 12 months) any of the following positions in any country:

1. Head of state or head of a country or government
YesNo

2. Government minister or equivalent senior politician
YesNo

3. Supreme court judge or equivalent senior judge
YesNo

4. Governor of a central bank or any other position that has comparable influence to the governor of the Reserve Bank of New Zealand
YesNo

5. Senior foreign representative, ambassador, or high commissioner
YesNo

6. High-ranking member of the armed forces
YesNo

7. Board chair, chief executive, or chief financial officer of, or any other position that has comparable influence in, any state enterprise
YesNo

Beneficial Ownership

Do you have:

1. Joint beneficial ownership of a legal entity or arrangement (e.g. a trust), or any other close relationship, with a person in any of the positions above?
YesNo

2. Sole beneficial ownership of a legal entity or arrangement (e.g. a trust) that to exists for the benefit of a person in any of the positions above?
YesNo

* The term 'Immediate family member' means:

• a spouse or partner (a person who is considered by relevant national law as equivalent to a spouse);

• a child, and a child’s spouse or partner; or

• a parent.

Section E: Acknowledgment

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, as 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 confirm that you are authorised to provide personal details presented and you consent to your information being checked with the documents issuer or official record holder via third party systems for the purpose of confirming your identity.

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

3. Personal Information and Privacy Act

• Creating and maintaining risk related models, including but not limited to risk assessment, risk analysis and risk management;

• Fulfilling reporting obligations, including but not limited to Annual AML/CFT Report, SAR, PTR, CRS, FATCA and any other reporting obligations imposed by New Zealand laws and regulations;

• Responding to the inquiries of banks or any other regulatory bodies;

• Marketing products, services and other subjects under the umbrella of Collinson & Co;

• 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 bodies or other authorities to comply;

• Any other purposes relating to the purposes listed above.

Notwithstanding the foregoing, I/we acknowledge that where a suspicious activity 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.

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

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 offence that Inland Revenue can apply. Substantial criminal penalties can be imposed by the courts for knowledge-based offences. These penalties apply for the purposes of both FATCA and CRS.

Confirmation

I confirm to consent:

Terms & Conditions:

The Client consents to Direct FX using information gathered from the Client during the application process, being used to electronically verify the Clients identify, for the purpose of compliance with the Anti-Money Laundering and Countering Financing of Terrorism Act 2009.e. The Client consents to Direct FX passing information gathered from the Client during the application process, to Data Zoo (NZ) Ltd, for the sole purpose of verifying the Clients identify, for the purpose of compliance with the Anti-Money Laundering and Countering Financing
of Terrorism Act 2009.

Declaration and Signature

By signing this form, I agree and confirm that:

- My answers above are correct

- I will promptly send confirmation should my answer in any category above change in the future.

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