Fillable CertiedCopyCerticate Customer Identication Documents(TobeusedforIndividualsonly) (Australian National University)

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CertiedCopyCerticate Customer Identication Documents(TobeusedforIndividualsonly) (Australian National University)

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Page1of3 P/C2026(02/09)153562WestpacBankingCorporation33007457141
CertiedCopyCerticate– Customer Identication Documents(TobeusedforIndividualsonly)
UponinstructionfromtheBank,thisformmaybeusedwherethecustomerisnotabletopresenttheiroriginalidenticationdocumentstotheBankinperson.
Part A: Customer Details
Fullname Dateofbirth

//
Residentialaddress
Suburb State Postcode Country
Signatureofcustomer(to be signed in the presence of the certier)
Part B: Certier Details
PleasecompletePartBtoenabletheBanktocontactyouifnecessarytoconrmanyinformationprovidedonthisform.
Fullname Occupation

Placeofemployment Businessphonenumber

()
Employmentaddress
Suburb State Postcode Country
Categoryofcertier(see list on page 3 – insert relevant number)
Wherethenameontheidenticationdocumentsdiffersfromthenameusedbythecustomer,provideanexplanationgivenbythecustomerorsight
andrecorddocumentationwhichidentiesthecustomerintheirformernamee.g.marriagecerticateordeedpoll.
Signature of Certier
• IhaveexaminedtheoriginalsofallthedocumentswhicharesetoutinPart Cofthisform.
• Thecopydocumentsattachedaretrueandcorrectcopiesoftheoriginaldocumentsexaminedbyme.
• Thecustomersignedthisforminmypresence.
Privacy Statement:TheBankiscollectingyourpersonalinformationinordertoassistintheidenticationoftheCustomernamedinPartA.
Signature Date
//
Attachcertied
copieshere
RESET
Page2of3 P/C2026(02/09)153562
Part C: Details of Documents Certied
• Atleasttwo identication documentsmustbecertiedwithatleastonebeinga primary identication document.
• Thecombinationofidenticationdocumentscertiedmustcontainthecustomer’sfull name,residential address anddate of birth.
• Certifytherstpageofthedocument(s)with“Thisisatruecopyoftheoriginaldocument”followedbytheCertier’ssignatureandthedate.Initial
anysubsequentpages.
• Alldocumentsmust be current unless specied otherwise.
• IfanydocumentiswritteninalanguageotherthanEnglish,itmustbeaccompaniedbyanEnglishtranslationpreparedbyanaccreditedtranslator.
Primary identication documents –pleasetick(3)whichdocument(s)arecertied.
Document Certied
Birthcerticate–Australian(mustbeafullbirthcerticate)......................................................................................................................................................................
Birthcerticate–Foreign(issuedbyaforeigngovernment,theUnitedNationsoranagencyoftheUnitedNations;mustbeafullbirthcerticate)
NSWbirthcard*.........................................................................................................................................................................................................................................................
Citizenshipcerticate–Australian......................................................................................................................................................................................................................
Citizenshipcerticate–Foreign(issuedbyaforeigngovernment).........................................................................................................................................................
Driver’slicence–Australian*.................................................................................................................................................................................................................................
Learner’sdriver’slicence–Australian*...............................................................................................................................................................................................................
Passport–Australian(caneitherbecurrentorexpiredwithinthelast2years;mustnotbecancelled,defacedormutilated)*.......................................
Passport–Foreign(issuedbyaforeigngovernment,theUnitedNationsoranagencyoftheUnitedNations;
mustnotbecancelled,defacedormutilated)*................................................................................................................................................................................................
Traveldocument–Foreign(issuedbyaforeigngovernment,theUnitedNationsoranagencyoftheUnitedNations)*.....................................................
Boatlicence–Australian*.......................................................................................................................................................................................................................................
Taxilicence–Australian*........................................................................................................................................................................................................................................
Pensioncard–Centrelink......................................................................................................................................................................................................................................
Pensioncard–DepartmentofVeterans’Affairs............................................................................................................................................................................................
KEYPASSphotoIDcard*.....................................................................................................................................................................................................................................
18+Proofofagecard*...........................................................................................................................................................................................................................................
Nationalidentitycard(issuedbyaforeigngovernment,theUnitedNationsoranagencyoftheUnitedNations)*.................................................................
NSWRTAphotocardorProofofagecard*...................................................................................................................................................................................................
*mustcontainaphotographandsignature
Secondary identication documents –pleasetick(3)whichdocument(s)arecertied.
Document Certied
Driver’slicence–Foreign*......................................................................................................................................................................................................................................
Securityguard’slicence*.........................................................................................................................................................................................................................................
Shooter’s/rearmslicence*.....................................................................................................................................................................................................................................
BlindCitizensAustraliaIDcard*...........................................................................................................................................................................................................................
MultipleSclerosisSocietyphotoIDcard*.........................................................................................................................................................................................................
PublicServiceemployeeIDcard–Australian*...............................................................................................................................................................................................
StudentIDcard–Australianhighereducation(TAFEorUniversity)*......................................................................................................................................................
WorkingWithChildrencheckcard(Bluecard)QLD,VIC,WA*..............................................................................................................................................................
AustralianTaxationOfce(ATO)noticeissuedwithinthelast12monthsandincludesthecustomer’snameandresidentialaddress...........................
FinancialbenetsnoticeissuedbyaCommonwealth,StateorTerritorygovernmentissuedwithinthelast12monthsandincludes
thecustomer’snameandresidentialaddress(e.g.anoticefromCentrelink).......................................................................................................................................
Financialinstitutionpassbook(Australian)whichmustbecurrentandhaveablacklightsignature.........................................................................................
Utilitiesnoticeissuedbyalocalgovernmentorutilitiesproviderwithinthelast3monthsandincludesthecustomer’snameandresidentialaddress...
Healthcarecard–Centrelink................................................................................................................................................................................................................................
Healthcarecard–DepartmentofVeterans’Affairs.......................................................................................................................................................................................
Marriagecerticate–Australian...........................................................................................................................................................................................................................
Medicarecard.............................................................................................................................................................................................................................................................
CommonwealthseniorshealthcardorStateseniorscard..........................................................................................................................................................................
*mustcontainaphotographand/orsignature
Page3of3 P/C2026(02/09)153562
Checklist for Certier (must be completed in full by the Certier)
Pleasetick(3)
Allpartsofthisformhavebeencompleted.
Youareapersonwithinaspeciedclassofacceptedcertiersdenedbelowin“CategoryofCertiers”.
 Allidenticationdocumentsarecertiedasatruecopyoftheoriginaldocument.
 Atleasttwoidenticationdocumentsarecertiedwithatleastonebeingaprimaryidenticationdocument.
 Thecombinationofidenticationdocumentscertiedcontainsthecustomer’sfullname,residentialaddressanddateofbirth.
 Thisformwassignedbythecustomerinyourpresence.
Thecertiedcopiesareattachedtothisform.
NOTE:ItisanoffenceundertheAnti-MoneyLaunderingandCounter-TerrorismFinancingAct2006toknowinglyprovidefalseormisleading
informationorknowinglyproduceafalseormisleadingdocument.Penalty: Imprisonment for 10 years.
Category of Certiers
(Note: Overseas customers can ONLY use category 11 or 16 below)
1. ApersonwhoisenrolledontherolloftheSupremeCourtof
aStateorTerritory,ortheHighCourtofAustralia,asalegal
practitioner(howeverdescribed)
2. Ajudgeofacourt
3. Amagistrate
4. AchiefexecutiveofcerofaCommonwealthcourt
5. Aregistrarordeputyregistrarofacourt
6. AJusticeofthePeace
7. Anotarypublic(forthepurposesoftheStatutoryDeclaration
Regulations1993)
8. Apoliceofcer
9. AnagentoftheAustralianPostalCorporationwhoisincharge
ofanofcesupplyingpostalservicestothepublic
10.ApermanentemployeeoftheAustralianPostalCorporationwith
2ormoreyearsofcontinuousservicewhoisemployedinan
ofcesupplyingpostalservicestothepublic
11.AnAustralianconsularofceroranAustraliandiplomaticofcer
(withinthemeaningoftheConsularFeesAct1955)
12. Anofcerwith2ormorecontinuousyearsofservicewithone
ormorenancialinstitutions(forthepurposesoftheStatutory
DeclarationRegulations1993)
13.Anancecompanyofcerwith2ormorecontinuousyearsof
servicewithoneormorenancecompanies(forthepurposesof
theStatutoryDeclarationRegulations1993)
14.Anofcerwith,orauthorisedrepresentativeof,aholderof
anAustraliannancialserviceslicence,having2ormore
continuousyearsofservicewithoneormorelicensees
15.AmemberoftheInstituteofCharteredAccountantsinAustralia,
CPAAustraliaortheNationalInstituteofAccountantswith2or
moreyearsofcontinuousmembership
16. Aninternationalbankemployeeauthorisedbytheirinstitutionto
openaccounts,wheretheinternationalbankisacceptableto
theBank
Bank use only
Bankofcer’sname Salarynumber

Branch/Department BSB CustomerIDVNumber
Signature Date
//
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CertiedCopyCerticate Customer Identication Documents(TobeusedforIndividualsonly) (Australian National University)

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Completed 1 February 2022

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