Online Adviser Form

- PRINCIPAL FINANCIAL ADVISER
- ASSOCIATE

PERSONAL DETAILS
GENERAL DETAILS
TITLE*
- Mr
- Mrs
- Ms
- Miss
FIRST NAME*
MIDDLE NAME(S)
SURNAME*
DATE OF BIRTH*
DD slash MM slash YYYY
HOME ADDRESS
ADDRESS*
SUBURB*
CITY/REGION*
POSTCODE*
Home Phone Prefix
HOME PHONE
Mobile Prefix
MOBILE
IDENTIFICATION
Please attach Photo ID, colour scan of;
- Personal details page of the Applicants current Passport; or
- NZ Firearms Licence; or
- NZ Drivers Licence
These file types are recommended: .jpg, .png, .pdf, .doc, .docx*
Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 120 MB.
These file types are recommended: .jpg, .png, .pdf, .doc, .docx

BUSINESS DETAILS
GENERAL DETAILS
LEGAL NAME OF ENTITY (FOR AGREEMENT)*
BROKERAGE OR COMPANY NAME*
EMAIL ADDRESS*
EMAIL ADDRESS FOR NEW BUSINESS CORRESPONDENCE
EMAIL ADDRESS FOR COMMISSION STATEMENTS
Business Phone Prefix
BUSINESS PHONE
Mobile Prefix
MOBILE
PHYSICAL ADDRESS
ADDRESS LINE 1*
ADDRESS LINE 2
SUBURB*
CITY/REGION*
POSTCODE*
POSTAL ADDRESS (IF DIFFERENT)
ADDRESS LINE 1
ADDRESS LINE 2
SUBURB
CITY/REGION
POSTCODE

FINANCE DETAILS
TAX
ARE YOU GST REGISTERED*
- Yes
- No
GST NUMBER*
IRD NUMBER

(Not required if trading as a company)
If you are not trading as a limited company, do you hold a Certificate of Exemption for withholding tax?*
Do you hold Certificate of Exemption for withholding tax
- Yes
- No
Please attach a copy of your Certificate of Exemption.*
Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 16 MB.
These file types are recommended: .jpg, .png, .pdf, .doc, .docx
BANK DETAILS
Please attach a bank deposit slip or screen shot of bank number incorporating the bank account name.
These file types are recommended: .jpg, .png, .pdf, .doc, .docx
Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 16 MB.
These file types are recommended: .jpg, .png, .pdf, .doc, .docx
PROFESSIONAL INDEMNITY INSURANCE
Please attach a copy of your current policy schedule or a letter confirming your cover under a current professional indemnity policy. Minimum cover required is $1m per Principal Adviser or $500k per Associate Adviser (to a maximum amount of $10m).
These file types are recommended: .jpg, .png, .pdf, .doc, .docx*
Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 16 MB.
These file types are recommended: .jpg, .png, .pdf, .doc, .docx
DISCLOSURE STATEMENT
For your protection we will undertake a compliance check on your behalf and will ensure your disclosure statement will match the requirements. Please attach a copy of your disclosure statement which is a requirement under New Zealand legislation.
These file types are recommended: .jpg, .png, .pdf, .doc, .docx*
Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 16 MB.
These file types are recommended: .jpg, .png, .pdf, .doc, .docx

EMPLOYMENT DETAILS
EMPLOYMENT HISTORY
PLEASE PROVIDE DETAILS OF YOUR LAST 5 YEARS EMPLOYMENT*
Date Name of Employer City/Country Role
PLEASE PROVIDE DETAILS OF ANY RELEVANT SALES EXPERIENCE*
Service/Product Name of Employer Source of business/sales
REFERENCES
Please provide the names and addresses of two past employers or supervisors or industry references.
REFEREE 1
Name*
Address*
Email address*
Phone Number Prefix
Phone number*
REFEREE 2
Name*
Address*
Email address*
Phone Number Prefix
Phone number*
CURRENT MEMBERSHIPS
Please describe any relationship you have or have had with any industry group
Member of Dealer Group
FSP Registration Number*
Current Disputes Resolution Scheme Name*
Current Disputes Resolution Scheme Number*

PERSONAL HISTORY
LIQUIDATION, BANKRUPTCY OR RECEIVERSHIP
Have you ever been adjudged bankrupt or been the director of a company that has gone into liquidation or receivership, or have you ever been prohibited by any legislation or a court or have any actions pending from taking part in the management of a business or a company? If yes, please provide details.
CONVICTIONS*
Please advise if, in the last 5 years, you have been convicted or have any actions pending of any offence against the Securities Markets Amendment Act 2006 or of any crime involving dishonesty or a director or principal officer of a company convicted of such an offence.*
CURRENT AGENCIES
Do you have any active agencies with other companies?*
- Yes
- No
COMPANY*
CURRENT PERSISTENCY*
APPROXIMATE API IN FORCE (BOOK SIZE)*
COMPANY
CURRENT PERSISTENCY
APPROXIMATE API IN FORCE (BOOK SIZE)
COMPANY
CURRENT PERSISTENCY
APPROXIMATE API IN FORCE (BOOK SIZE)
COMPANY
CURRENT PERSISTENCY
APPROXIMATE API IN FORCE (BOOK SIZE)
RESIDENCY STATUS
Please advise your New Zealand residency status
AGENCY HISTORY
Have you ever had an agency terminated or declined by another company? If yes, please provide details.
CREDIT CHECK
As part of this application Cactus will carry out a credit check and/or PPSR, and may ask for further details regarding any defaults recorded on the credit check report. Cactus also reserves the right to carry out a credit check from time to time at our sole discretion. We reserve the right to pass this information to your Principal.

DECLARATIONS
PRIVACY ACT 1993
This Financial Adviser Application form collects personal information about you in order to assess and process your application. Failure to provide this information may result in your application being declined. This information is collected by Cactus and will be held at Cactus’ Auckland head office. You have certain rights of access to, and correction of, your personal information under the Privacy Act 1993.
DECLARATION
I hereby apply for appointment as a financial adviser with Cactus and declare and agree as follows:
- To the best of my knowledge the information and answers to questions contained in this application are true and correct.
- I have not withheld any information that would influence Cactus’ decision in respect of the application.
- To maintain Professional Indemnity Insurance as required by the Cactus Adviser Agreement on acceptance of this application by Cactus.
- I authorise Cactus to request credit checks and/or PPSR and collect any personal information relevant to this application. In collecting this information, I agree that Cactus is not required to make me aware that such information is being collected.
ADMINISTRATION PROCESS
In order for your application to be processed, Cactus requires all documentation as listed in the attached checklist, and any other information requested by Cactus for the purpose of assessing your application at our sole discretion. In the event this is not received, we will return your application back to you for completion.
AGENCY PROCESS
Please note this application form does not constitute an acceptance of an agency agreement, nor does it entitle you to quote or apply for Cactus products either for yourself or your clients.
*
- I AGREE TO THE TERMS AND CONDITIONS OF THIS APPLICATION*
FULL NAME*
DATE*
DD slash MM slash YYYY
If you are applying to be an Associate and work with an Agency what is the name of the Principal Agency you will be working under?

Date	Name of Employer	City/Country	Role

Service/Product	Name of Employer	Source of business/sales

PERSONAL DETAILS

GENERAL DETAILS

HOME ADDRESS

IDENTIFICATION

BUSINESS DETAILS

GENERAL DETAILS

PHYSICAL ADDRESS

POSTAL ADDRESS (IF DIFFERENT)

FINANCE DETAILS

TAX

BANK DETAILS

PROFESSIONAL INDEMNITY INSURANCE

DISCLOSURE STATEMENT

EMPLOYMENT DETAILS

EMPLOYMENT HISTORY

REFERENCES

CURRENT MEMBERSHIPS

PERSONAL HISTORY

LIQUIDATION, BANKRUPTCY OR RECEIVERSHIP

CONVICTIONS*

CURRENT AGENCIES

RESIDENCY STATUS

AGENCY HISTORY

CREDIT CHECK

DECLARATIONS

PRIVACY ACT 1993

DECLARATION

ADMINISTRATION PROCESS

AGENCY PROCESS