APPLICATION FOR A BROKERAGE CONTRACT TO ACT AS … · APPLICATION FOR A BROKERAGE CONTRACT TO ACT...
Transcript of APPLICATION FOR A BROKERAGE CONTRACT TO ACT AS … · APPLICATION FOR A BROKERAGE CONTRACT TO ACT...
APPLICATION FOR A BROKERAGE CONTRACT TO ACT AS INTERMEDIARY
1. OFFICE USE ONLY
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FG number
F G
Consultant
2. IMPORTANT NOTES
1.Fedgroup comprises of the following entities:1.1 Fedgroup Participation Bond Managers Pty Ltd1.2 Fedgroup Life Limited Ltd1.3 Fedgroup Trust Administrators Pty Ltd1.4 Fedgroup Fund Administrators Pty Ltd 1.5 Fedgroup Asset Management Pty Ltd1.6 Fedgroup Employee Benefits Pty Ltd1.7 Fedgroup Financial Services Pty Ltd
2. “Brokerage” refers to the entity that has been registered as FSP in terms of FAIS (company, firm, etc)3. “Financial Planner” refers to a broker giving advice
3. PARTICULARS OF BROKERAGE
Type of business
Company Close Corporation Sole Proprietor Partnership
Registered name of business
Nature of business
Registration number (if applicable)
Physical address Postal address
Code Code
Full name/s
3A. BROKERAGE PRINCIPAL
Title Initials Surname
ID or passport number Date of birth
DDGender
FMMM YY YYDesignation
89 Bute Lane, Sandton. PO Box 782823, Sandton, 2146. T 011 305 2323 E [email protected] W fedgroup.co.za
Initial
Fedgroup Asset Management Pty Ltd (Reg. No. 1997/007878/07) Auth FSP. 665, License 13B: No. 24/536Fedgroup Life Ltd (Reg. No. 2007/018003/06) Auth FSP. 40607Fedgroup Employee Benefits Pty Ltd (Reg. No. 2008/013532/07) License 13B: No. 24/493Fedgroup Trust Administrators Pty Ltd (Reg. No. 1951/003389/07) Auth FSP. 16302, License 13B: No. 24/505
Fedgroup Participation Bond Managers Pty Ltd (Reg. No. 1956/001143/07) CIS 804Fedgroup Financial Services Pty Ltd (Reg. No. 2012/000697/07) Auth FSP. 45563Fedgroup Fund Administrators Pty Ltd (Reg. No. 1990/002515/07) Auth FSP. 45563 FSP: 26/10/6690
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ID or passport number Date of birth
DDGender
FMMM YY YYDesignation
Cell number
Brokerage Income Tax number
Tel number
FSP registration number
VAT number
Cell number
Tel number
Residential Address
VAT number
Full name/s
Title Initials Surname
ID or passport number Date of birth
DDGender
FMMM YY YYDesignation
Cell number
Tel number
Residential address
VAT number
Full name/s
Title Initials Surname
89 Bute Lane, Sandton. PO Box 782823, Sandton, 2146. T 011 305 2323 E [email protected] W fedgroup.co.za
3A. BROKERAGE PRINCIPAL (CONTINUED)
3B. DIRECTOR
3C. DIRECTOR
Initial
Fedgroup Asset Management Pty Ltd (Reg. No. 1997/007878/07) Auth FSP. 665, License 13B: No. 24/536Fedgroup Life Ltd (Reg. No. 2007/018003/06) Auth FSP. 40607Fedgroup Employee Benefits Pty Ltd (Reg. No. 2008/013532/07) License 13B: No. 24/493Fedgroup Trust Administrators Pty Ltd (Reg. No. 1951/003389/07) Auth FSP. 16302, License 13B: No. 24/505
Fedgroup Participation Bond Managers Pty Ltd (Reg. No. 1956/001143/07) CIS 804Fedgroup Financial Services Pty Ltd (Reg. No. 2012/000697/07) Auth FSP. 45563Fedgroup Fund Administrators Pty Ltd (Reg. No. 1990/002515/07) Auth FSP. 45563 FSP: 26/10/6690
5. WHERE APPLICABLE, ATTACH THE FOLLOWING DOCUMENTS
6. PLEASE INDICATE WHICH PRODUCT YOU WOULD LIKE TO MARKET
Please tick the appropriate box
Secured Investment Fiduciary Services Distinction Umbrella
Fund Administration Asset Management
Group Risk Funeral Product Linked Investment Products Critical illness Product
Disability Product
Copy of the FAIS license (including conditios and restrictions)
Copy of the VAT registration certificate and Income Tax Certificate
Copies of Broker principle and each Directors (ID Document, proof of residence)
Copy of proof of bank account (not older than three months)
Utility bill for brokerage not older than 3 months
Copy of notice of registered office and postal address bearing stamp of registrar companies
Most recent certificate of incorporation bearing stamp of registrar of companies
RE1 & RE5 certificate of KI
Designation
Full name/s
Title Initials Surname
ID number Contact number
4. CONTACT PERSON DETAILS (PERSON WITH WHOM FEDGROUP MUST COMMUNICATE)
Tax clearance certificate
Name of account holder
Name of bank Account no
Branch name Branch no
7. BANKING DETAILS (FOR COMMISSION PAYMENTS)
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89 Bute Lane, Sandton. PO Box 782823, Sandton, 2146. T 011 305 2323 E [email protected] W fedgroup.co.za
Initial
Fedgroup Asset Management Pty Ltd (Reg. No. 1997/007878/07) Auth FSP. 665, License 13B: No. 24/536Fedgroup Life Ltd (Reg. No. 2007/018003/06) Auth FSP. 40607Fedgroup Employee Benefits Pty Ltd (Reg. No. 2008/013532/07) License 13B: No. 24/493Fedgroup Trust Administrators Pty Ltd (Reg. No. 1951/003389/07) Auth FSP. 16302, License 13B: No. 24/505
Fedgroup Participation Bond Managers Pty Ltd (Reg. No. 1956/001143/07) CIS 804Fedgroup Financial Services Pty Ltd (Reg. No. 2012/000697/07) Auth FSP. 45563Fedgroup Fund Administrators Pty Ltd (Reg. No. 1990/002515/07) Auth FSP. 45563 FSP: 26/10/6690
Beneficiary Care Education Product Bonds
CIS Products Retirement Annuity
8. AUTHORISATION AND DECLARTION (ON BEHALF OF THE BROKERAGE)
1. The brokerage authorises Fedgroup to obtain information from third parties to ascertain the brokerage's fit and proper status, also of its key individuals and representatives.
2. It is acknowledged that the brokerage is not authorised to canvass business for Fedgroup until such time that the brokerage has received an approval to act as Fedgroup intermediary letter. Should the brokerage canvass any business prematurely, Fedgroup will at its own discretion decide whether or not the brokerage should receive payment for such business.
3. It is agreed that, should Fedgroup enter into a brokerage contract with the brokerage, this application will form part of such contract.
4. It is declared and agreed that the agreement shall be dealt with in terms of the contract with regards to any suspension or termination, should any of the following occur: - Any of the information provided on behalf of the brokerage to Fedgroup Financial Services is incorrect and/or incomplete - Fedgroup enters into a brokerage contract with the brokerage and the brokerage subsequently neglects, or fails to inform and provide Fedgroup with full details under the following circumstances: - An additional financial planner is appointed by the brokerage - A financial planner terminates his or her services with the brokerage - There are changes with regards to the business or the board, members and/or shareholders pertaining to the brokerage - The brokerage’s business address changes - The brokerage’s financial services provider licence is suspended and/or not renewed - Any changes that occur to any of the brokerage’s key individuals and representatives
5. I agree that my contractual relationship with Fedgroup Employee Benefits will be subject to South African law and regulation (including but not limited to Financial Intelligence Control Act, Exchange Control and tax requirements.
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9. BROKERAGE PRINCIPAL/DIRECTOR/SHAREHOLDER/KEY INDIVIDUAL
Name and surname
in my capacity as
(place)at
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89 Bute Lane, Sandton. PO Box 782823, Sandton, 2146. T 011 305 2323 E [email protected] W fedgroup.co.za
Brokerage principal/sole proprietor signature Date
DD MM YY YY
Key individual signature
Or
Or
Date
DD MM YY YY
Director/shareholder Date
DD MM YY YY
Type of account
TransmissionCurrent Savings
Commission remittance/statement to be emailed to, if different to contact person
7. BANKING DETAILS (FOR COMMISSION PAYMENTS)
Initial
Fedgroup Asset Management Pty Ltd (Reg. No. 1997/007878/07) Auth FSP. 665, License 13B: No. 24/536Fedgroup Life Ltd (Reg. No. 2007/018003/06) Auth FSP. 40607Fedgroup Employee Benefits Pty Ltd (Reg. No. 2008/013532/07) License 13B: No. 24/493Fedgroup Trust Administrators Pty Ltd (Reg. No. 1951/003389/07) Auth FSP. 16302, License 13B: No. 24/505
Fedgroup Participation Bond Managers Pty Ltd (Reg. No. 1956/001143/07) CIS 804Fedgroup Financial Services Pty Ltd (Reg. No. 2012/000697/07) Auth FSP. 45563Fedgroup Fund Administrators Pty Ltd (Reg. No. 1990/002515/07) Auth FSP. 45563 FSP: 26/10/6690
Full name/s and surname
Contact number Contact number
Full name/s and surname
Contact number Contact number
Full name/s and surname
Contact number Contact number
10. SHAREHOLDERS
Information RequiredA list of shareholders who hold 25% or more of the company’s shares and the percentage of shares held by each such shareholder.
Verification (provide certified copies of the documents listed in this column)Share certificates or a share register in respect of shareholders holding 25% or more of the shares or voting rights in the client.
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89 Bute Lane, Sandton. PO Box 782823, Sandton, 2146. T 011 305 2323 E [email protected] W fedgroup.co.za
Initial
Fedgroup Asset Management Pty Ltd (Reg. No. 1997/007878/07) Auth FSP. 665, License 13B: No. 24/536Fedgroup Life Ltd (Reg. No. 2007/018003/06) Auth FSP. 40607Fedgroup Employee Benefits Pty Ltd (Reg. No. 2008/013532/07) License 13B: No. 24/493Fedgroup Trust Administrators Pty Ltd (Reg. No. 1951/003389/07) Auth FSP. 16302, License 13B: No. 24/505
Fedgroup Participation Bond Managers Pty Ltd (Reg. No. 1956/001143/07) CIS 804Fedgroup Financial Services Pty Ltd (Reg. No. 2012/000697/07) Auth FSP. 45563Fedgroup Fund Administrators Pty Ltd (Reg. No. 1990/002515/07) Auth FSP. 45563 FSP: 26/10/6690
Shareholder 1
Shareholder 2
Shareholder 3
Full name/s and surname
Contact number Contact number
Shareholder 4
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89 Bute Lane, Sandton. PO Box 782823, Sandton, 2146. T 011 305 2323 E [email protected] W fedgroup.co.za
Initial
Fedgroup Asset Management Pty Ltd (Reg. No. 1997/007878/07) Auth FSP. 665, License 13B: No. 24/536Fedgroup Life Ltd (Reg. No. 2007/018003/06) Auth FSP. 40607Fedgroup Employee Benefits Pty Ltd (Reg. No. 2008/013532/07) License 13B: No. 24/493Fedgroup Trust Administrators Pty Ltd (Reg. No. 1951/003389/07) Auth FSP. 16302, License 13B: No. 24/505
Fedgroup Participation Bond Managers Pty Ltd (Reg. No. 1956/001143/07) CIS 804Fedgroup Financial Services Pty Ltd (Reg. No. 2012/000697/07) Auth FSP. 45563Fedgroup Fund Administrators Pty Ltd (Reg. No. 1990/002515/07) Auth FSP. 45563 FSP: 26/10/6690
11. SHAREHOLDERS
11A. A NATURAL PERSON
Information RequiredPlease provide the following information where applicable – where the above-listed shareholder is:
A certified copy of the person’s green bar-coded ID document, valid SA driver’s license (or valid passport if foreign).
ID or passport number Date of birth
DD MM YY YY
Full name/s
Physical address Nationality (if not South African)
Code
11B. A PRIVATE COMPANY OR CLOSE CORPORATION (FOREIGN OR LOCAL):
Most recent certificate of incorporation and notice of registered office and postal address, bearing the stamp of the Register of Companies and signed by the company secretary.
Proof of business address such as a utility bill, bank statement or similar document (not older than three months).
Registered name of business
Trade name
Registration number (if applicable)
Registered address Business address
Code Code
11D. TRUST
The trust deed or other founding document in terms of which the trust is created.
Name of the trust
Trust number
Trust’s address
Code
11E. OTHER ENTITY:
The constitution or other founding document in terms of which the legal person is created.
Proof of business address such as a utility bill, bank statement or similar document (not older than three months).
Name of the legal person
Its legal form
Address from which it operates
Code
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89 Bute Lane, Sandton. PO Box 782823, Sandton, 2146. T 011 305 2323 E [email protected] W fedgroup.co.za
Initial
Fedgroup Asset Management Pty Ltd (Reg. No. 1997/007878/07) Auth FSP. 665, License 13B: No. 24/536Fedgroup Life Ltd (Reg. No. 2007/018003/06) Auth FSP. 40607Fedgroup Employee Benefits Pty Ltd (Reg. No. 2008/013532/07) License 13B: No. 24/493Fedgroup Trust Administrators Pty Ltd (Reg. No. 1951/003389/07) Auth FSP. 16302, License 13B: No. 24/505
Fedgroup Participation Bond Managers Pty Ltd (Reg. No. 1956/001143/07) CIS 804Fedgroup Financial Services Pty Ltd (Reg. No. 2012/000697/07) Auth FSP. 45563Fedgroup Fund Administrators Pty Ltd (Reg. No. 1990/002515/07) Auth FSP. 45563 FSP: 26/10/6690
11C. PARTNERSHIP
The partnership agreement in terms of which the partnership was formed.
Registration number (if applicable)
Registered address
Code
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89 Bute Lane, Sandton. PO Box 782823, Sandton, 2146. T 011 305 2323 E [email protected] W fedgroup.co.za
Date
DD MM YY YY
Initial
Fedgroup Asset Management Pty Ltd (Reg. No. 1997/007878/07) Auth FSP. 665, License 13B: No. 24/536Fedgroup Life Ltd (Reg. No. 2007/018003/06) Auth FSP. 40607Fedgroup Employee Benefits Pty Ltd (Reg. No. 2008/013532/07) License 13B: No. 24/493Fedgroup Trust Administrators Pty Ltd (Reg. No. 1951/003389/07) Auth FSP. 16302, License 13B: No. 24/505
Fedgroup Participation Bond Managers Pty Ltd (Reg. No. 1956/001143/07) CIS 804Fedgroup Financial Services Pty Ltd (Reg. No. 2012/000697/07) Auth FSP. 45563Fedgroup Fund Administrators Pty Ltd (Reg. No. 1990/002515/07) Auth FSP. 45563 FSP: 26/10/6690
11F. DECLARATION
We confirm that the above information is true and correct to the best of our knowledge and belief, and enclose copies of the requested verification documentation.
Signed
(Client name)
(authorised signatory
who warrants his/her authority) on behalf of