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Application To Become An Accredited Broker

Please complete all sections of the application. 

Each application is subject to assessment and this application does not constitute a commercial agreement. ALA Funding may, in its absolute discretion refuse to approve an application.

Section A

(1)

Are you an Aggregator/Franchisor?

 Yes No
(2)

If yes, Name?

(3)

If no, indicate if you belong to an aggregator, franchise group or an independent

 Aggregator Member
 Franchise Member
 Independent
(4)

Are you currently a member of MFAA (Formerly MIAA) or / and FBAA?

 Yes No
(5)

Do you have Professional Indemnity (PI) Insurance cover?

 (If you have current PI insurance then attach certificate showing the amount the applicant is covered for and the expiry including “run-off” cover)

 Yes No
(6)

Government Identification Requirements

 (Attach a “certified copy of documents meeting Government Identification Requirements for each individual applicant. If you are unsure about documents that qualify, please contact your Business Development Manager.)

 Provided
(7)

Do you hold Credit Ombudsman Service Ltd (COSL) membership?

 (If you have COSL membership then attach the certificate OR proof of membership of an alternate External Dispute Resolution (EDR) scheme, and / or written approval by COSL. Visit www.creditombudsman.com.au)

 Yes No
(8)

Do you conduct business / operate in Western Australia (WA) or Australian Capital Territory (ACT)?

 (Please attach a copy of your relevant Licence that evidences that you are Licensed Finance Broker)

 

 Yes No

Section B

To be completed if you are applying for membership for a company, corporation or partnership

(1)

ABN

(2)

ACN

(3)

Organisation Name

(4)

Name of Corporate / Legal Entity

(5)

State of Incorporation

(6)

Address

(7)

Suburb/City

(8)

State

(9)

Postcode

(10)

Telephone

(11)

Facsimile

(12)

Mobile

(13)

Email

(14)

Postal Address Is the Same As Above

 Yes
 No
(15)

If no, Address

(16)

If no, Suburb / City

(17)

If no, State

(18)

If no, Postcode

Section C

Company / Partnership Contacts: Each director and partner should complete this section individually and sign the personal declaration and the privacy disclosure statement and consents. (Separate completed form for each individual)

(1)

Title

(2)

First Name

(3)

Last Name

(4)

Date Of Birth
(5)

Position

 Sole Director Director Partner Other
(6)

If Other Please Specify Position

(7)

Home Address

(8)

Suburb / City

(9)

State

(10)

Postcode

(11)

Home Telephone

(12)

Facsimile

(13)

Mobile

(14)

Email

2nd Director/Partner (if required)

(15)

Title

(16)

First Name

(17)

Last Name

(18)

Date Of Birth
(19)

Position

 Sole Director
 Director
 Partner
 Other
(20)

If Other Please Specify Position

(21)

Home Address

(22)

Suburb / City

(23)

State

(24)

Postcode

(25)

Home Telephone

(26)

Facsimile

(27)

Mobile

(28)

Email

Section C - Personal Declaration

In relation to the last 10 years, whether as an individual or Director of a company or partner of a firm, have you ever:

(1)

Had an industry or business licence, issued by a Proper Authority, either refused, suspended, withdrawn, cancelled or been subject to banning order, or do you have any of these actions pending?

 Yes No
(2)

Been convicted of or found to have committed an offence concerning fraud or dishonesty or do you have a charge pending involving fraud or dishonesty?

 Yes No
(3)

Been subject to an investigation by ASIC or by any other regulatory or official Body in relation to any aspect of its business or are you currently subject to such an investigation by any of these bodies?

 Yes No
(4)

Been a director of a company that has gone into voluntary liquidation or to which a Receiver, Provisional liquidator, Liquidator, Scheme Manager or an Official Manager has been appointed while you were a Director, or within six months after you ceased to be a Director, or do you have any such action pending?

 Yes No
(5)

Been declared bankrupt or are you presently an un-discharged bankrupt or do you have any such action pending?

 Yes No
(6)

Been a Partner of a firm which has been placed into voluntary liquidation or had a Receiver Provisional liquidator, Liquidator, Scheme Manager or an Official Manager appointed, or do you have any such action pending?

 Yes No
(7)

Been refused membership of a statutory, professional or other body in respect of your professional capacity or other Body in respect of your professional capacity, or do you have such action pending?

 Yes No
(8)

Been subject to disciplinary proceedings or banned, disqualified or expelled by a statutory, professional or other Body in respect of your professional capacity, or do you have such action pending?

 Yes No
(9)

Been dismissed, or had any proper authority including any licence withdrawn on ethical or legal grounds, or any disciplinary proceedings pending?

 Yes No
(10)

Had any past, present or pending claim made against your Professional Indemnity Insurance under which you operate in relation to advice you have provided?

 Yes No
(11)

Been refused Professional Indemnity Insurance?

 Yes No
(12)

Had your accreditation cancelled or suspended by a Lender, Mortgage Manager, or a Mortgage Insurer, other that for volume reasons, or had your membership of an aggregator or franchise group terminated, or is similar action pending against you?

 Yes No
(13)

Have you as an individual ever been known by any other name?

 Yes No

If you have answered “Yes” to any of the above questions from 1 to 13, please attach details as to why you answered as “Yes” and any details relating to the incident.