Page 19 - Longyard - Information Memorandum_Neat

APPLICATION FORM

This application form must not be handed on to another person unless attached to this Information Memorandum. For items (a) to (h) please refer to the guide. Income distribution instructions
Please use Block Letters (g) Please pay income by cheque to the address recorded in section (d) of this form
Please pay income to the Australian bank, building society or credit union account detailed below:

Name of Financial institution Type of account
I / we apply for
(a) Number of Units Amount payable Branch (full address)
X $1.00 =
Account
BSB Number number
Name (s) in which your account is held
Full name of Applicants (legal entities only)
(b) Applicant 1 Title Surname or company name (incl First name DOB
ACN)
Privacy Statement
Joint Title Surname or company name (incl First name DOB (h) The information collected by the Trustee from this Application Form is necessary to process your application, administer your investment,
Applicant 2 ACN) comply with relevant taxation laws and communicate with you on an ongoing basis. We will give you access to personal information we
hold on you on request. Our privacy policy is available from the Company free of charge, upon request. From time to time we may seek to
ensure that the personal information we hold about you is complete and up-to-date. Information relating to you and your investment may
be given to the Australian Taxation Office as required by law, from time to time, and may be given to the Company’s auditors, lawyers,
Joint Title Surname or company name (incl First name DOB registry and other service providers as required. By signing this Application form, the Applicant consents to the use and disclosure of
personal information as set out in this Application Form.
Applicant 3 ACN)
Please tick this box if you do not wish to receive information about future syndicate from time to time.

Declaration
Postal address (i) Each Applicant declares that:
(c) Number and street • This application is completed according to the declaration/appropriate statements on the guide to this form;
I agree to be bound by the Constitution of the Syndicate;
•
• The return of the Application Form with a cheque for the Application Monies will constitute an Offer to subscribe for Units in
the Syndicate
Suburb, city or town State Postcode • An Application cannot be withdrawn except by right under the Corporations Act or if the Trustee agree.

Investor signatures
(l) Applicant 1 signature Applicant 2 signature Applicant 3 signature

Tax file number or exemption codes
(d) Tax File Number (TFN) Or ABN Or Exemption Code
Date

Cheque details
(e) Drawer Bank Branch Amount $ Refer to the Supplementary Material for instructions on how to complete plus the required wholesale investor
declaration.

Drawer Bank Branch Amount $

Contact details
(f) Contact name Home tel Work tel. Mob tel. Email address
( ) ( ) ( )