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Personal Details

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Title

Mr Mrs Miss Ms

Surname

First Name

Other Name(s)

Preferred Name (If Different)

Have you ever been known by another name?

Yes No

Previous Name

Date of Birth

Number of years in Australia (If less than 10)

City of Birth

State of Birth

Driver Licence Number

State Issued

Expected Commencement Date

Contact Details

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Phone (Business)

Mobile

Email

Your Website

Current Employer

Position

Current Business Address

Suburb

State

Postcode

Operated here since (Month & Year)

Postal Address (If Different)

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Postal Address

Suburb

State

Postcode

Residential Address

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Residential Address

Suburb

State

Postcode

Home Phone

Lived here since (Month & Year)

Business Structure

Qualifications

Relevant Education / Courses Completed

Institution	Degree/Diploma/Certificate	Year Attained	Attachment	Action

Note: Attach copy of certificate(s) and transcript(s) for all relevant course work

Do you intend to provide Margin Lending advice?

Yes No

If yes, please provide evidence of relevant qualification

Do you intend to provide Self-Managed Super Fund Advice?

Yes No

If yes, please provide evidence of a relevant qualification

I`ve completed the education requirements.

I will be using the Experienced Provider Pathway.

I have you passed the Financial adviser exam.

If yes, Please provide statement of results

Courses Currently Being Undertaken

Institution	Degree/Diploma/Certificate	Type of course	Completion Due	Attachment	Action

Kaplan number (if applicable)

Continued learning

CPD maintained (40 pts).

Yes No

Note: Attach copy of transcripts including mandatory categories for past 3 years ongoing education (CPD) activity

Reason for not maintaining CPD (if applicable)

Adviser Experience

Do you or your business hold (or have you previously held) an AFS License, Dealer, Securities or Brokers Licence?

Yes No

Have you ever been authorised by an AFSL, securities dealer, investment adviser or insurance broker?

Yes No

If yes to either question, please provide details of any licences or authorities and state if they are current.

License Details

Details & ASIC Codes	Current?	Action
	Yes No

Financial Services Industry Experience

Start Date	End Date	Employer	Position	Details	Action

Current Professional Associations

FAAA

CPA

IPA

AIOFP

SMSF Association

Other (Specify)

Provide evidence of membership

About Your Current Business

Current Licensee

Current Total Annual Advice Revenue

Approx. Current FUA

Anticipated Revenue After 12 Months

Upfront Fees

Ongoing Revenue

Business Splits / Advice Revenue Sources

Retirement / Superannuation (%)

SMSF (%)

Investment (Non-Super) (%)

Insurance (%)

Briefly describe your business model (in what areas do you focus, source of new clients, other sources of revenue)

Product Providers

Wrap / Platform

Provider	FUM (Approx)	Action

Risk

Provider	Premium Pa (Approx)	Action

Other (Unlisted / Derivatives/ Precious Metals Etc)

Provider	FUM (Approx)	Action

Disclosures

Are you currently the Director of any company or did you ever hold a Directorship in the past 10 years?

Yes No

Provide Details

Positions Held During the Last 7 Years

Employer	Position	Date Commenced	Date Ceased	Actions

Is the applicant aware of any previous, current or future PI claims against him/her or the Corporate AR?

Yes No

Provide details

Is the applicant aware of any issue or complaint raised by clients or your current/previous licensee against the applicant including any with an AFSL, securities dealer, a life company or any other relevant body?

Yes No

Provide details

Alternate Revenue Sources / Related Party Interests / Other Business

List any other businesses associated with the Corporate Authorised Representative and/or individual where a fee is received:

Name of Business	Type of Business / Services Provided	Actions

Referees

The following persons may be approached by a representative of Lifespan Financial Planning for a reference on the applicant (please provide details of two business related referees):

Referee

Name

Company

Title

Relationship

Years Known

Phone

Referee

Name

Company

Title

Relationship

Years Known

Phone

Consent & Documentation

Consent, Declarations and Undertakings

Declarations

I declare that the statements made in this application and any attachments, are complete and true and that I am Not aware of anything which may preclude me from holding an Authority with Lifespan Financial Planning Pty Ltd.

I understand that background checks may be conducted by Lifespan Financial Planning Pty Ltd that may include any or all of the following: ASIC banning orders, causes, writs and court orders, and any other background search deemed appropriate by Lifespan Financial Planning Pty Ltd including Credit checks, Bankruptcy Notices or creditors petitions against an individual.

I also consent that Lifespan Financial Planning may, with prior Notice, and where deemed necessary, contact my previous or existing Licensee as part of assessing my suitability as an authorised representative of Lifespan Financial Planning Pty Ltd.

I agree to complete an Australian Federal Police Criminal History Name Check Application and forward the results to Lifespan.

I undertake to advise the Licensee, for so long as I am an Authorised Representative of the Licensee, of any changes to the information provided by me in this application.

I undertake to submit to all compliance and business reviews as required by the Licensee.

I undertake to submit to all ongoing training and education as required by the Licensee.

I undertake to submit to all reasonable Licensee requests as required from time to time.

I authorise the Licensee to provide a copy of my ID and second form of identification to product providers when requesting code on my behalf.

Supporting Documentation Requirements

Please return this application form together with:

Certified copy of Driver Licence and second form of identification (front and back for both documents)
Copies of 3 most recent Compliance Audit Report(s) if available
Copies of 3 recent client SoAs covering a range of advice scenarios in Word format (.doc), if available
Police Check outcome (when received)https://afpnationalpolicechecks.converga.com.au/
Signed Prospective AR Consent Form(Download AR Consent Form)
Signed PI Declaration Form(Download PI Declartion Form)

I have included all required documents.

Additional Comments

PLEASE NOTE: YOUR APPLICATION WILL NOT BE ASSESSED UNTIL ALL NECESSARY DOCUMENTATION HAS BEEN RECEIVED.

Company name

Personal Details

Contact Details

Postal Address (If Different)

Residential Address

Business Structure

Qualifications

Relevant Education / Courses Completed

Courses Currently Being Undertaken

Adviser Experience

License Details

Financial Services Industry Experience

About Your Current Business

Anticipated Revenue After 12 Months

Business Splits / Advice Revenue Sources

Product Providers

Wrap / Platform

Risk

Other (Unlisted / Derivatives/ Precious Metals Etc)

Disclosures

Positions Held During the Last 7 Years

Alternate Revenue Sources / Related Party Interests / Other Business

Declaration

Referees

Referee

Referee

Consent & Documentation

Consent, Declarations and Undertakings

Declarations

Supporting Documentation Requirements

Application Submitted Successfully!