Fillable Customer identification and broker declarations (face-to-face). (Australian National University)

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Customer identification and broker declarations (face-to-face). (Australian National University)

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Members Equity Bank Limited ABN 56 070 887 679 AFSL and Australian Credit Licence 229500. 1
Broker use only.
This form is used for:
• Face-to-face identity verification conducted in Australia either in person or via a digital platform. Note: If you cannot complete a face-to-face
interview, please contact your Business Development Manager to discuss verification of the applicant(s) identity.
• Broker declarations.
Identity verification.
Please complete the customer identification sections below for all applicants/guarantors.
Step 1 Record the details of the person(s) being identified.
Step 2 Sight the required original identification documents and record the verification method.
Step 3 Record details of the original identification documents sighted by you and verify that the person’s details match the
identification documents.
Step 4 Attach copies of the original identification documents to this completed form before submitting to ME.
Person(s) being identified.
Applicant 1. Applicant 2/Guarantor.
Title
(Mr/Mrs/Miss/Ms/other) Surname
Given name(s)
Date of birth
D
D
M
M
Y
Y
Y
Y
Residential address
State     Postcode
Date identification took place
D
D
M
M
Y
Y
Y
Y
Title (Mr/Mrs/Miss/Ms/other) Surname
Given name(s)
Date of birth
D
D
M
M
Y
Y
Y
Y
Residential address
State     Postcode
Date identification took place
D
D
M
M
Y
Y
Y
Y
Note – it is an offence under the Anti-Money Laundering and Counter-Terrorism Financing Act 2006 (Cth) to provide false or misleading
information or to produce false or misleading documents.
Privacy – the information provided by you on this form to verify your identity is collected in accordance with the Anti-Money Laundering
and Counter-Terrorism Financing Act 2006 (Cth). Information may be disclosed to the Australian Transaction Reports and Analysis Centre
(AUSTRAC) or as other legislation allows or requires.
Verification method.
Applicant 1. Applicant 2/Guarantor.
  In person
  Digital platform
Platform used e.g. Facetime
  In person
  Digital platform
Platform used e.g. Facetime
Customer identification
and broker declarations
(face-to-face).
For any enquiries contact the credit hotline
on 1300 728 154 or visit mebank.com.au/broker
Members Equity Bank Limited ABN 56 070 887 679 AFSL and Australian Credit Licence 229500. 2
Identification document requirements.
Option 1.
(supply one primary photographic
identification document)
Option 2.
(supply one primary non-photographic
identification & one secondary
identification document)
Option 3.
(supply two primary non-photographic
identification documents)
Primary photographic identification
document:
 Driver's licence or permit (Australian only)
 Passport (Australian or foreign*)
 Proof of Age card (Australian Only)
  National identity card issued by a foreign
government or United Nations
Primary non-photographic identification
document:
 Birth certificate (Australian or foreign*)
 Birth extract (Australian only)
 Pension card issued by Centrelink
  Citizenship certificate (Australian
or foreign*)
Secondary identification document
(must contain your full name and
residential address):
  Government financial benefits notice
(issued within the last 12 months)
  Australian Tax Office notice of assessment
(issued within the last 12 months)
  Local government or utilities bill
(issued within the last three months)
All documents must be original and current (with the exception of Australian passports expired within the last two years but not cancelled)
and contain the applicant’s full name, date of birth or current residential address.
*Foreign documents must be in English.
Record of identification document (copies to be attached).
Applicant 1.
Document type (e.g. passport)
Name verified? Yes  No 
Document number (if applicable) Date of birth verified? Yes  No 
Document issue date (if applicable) Residential address verified? Yes  No 
Place of issue (if applicable) Photograph verified? N/A  Yes  No 
Document expiry date
D
D
Y
Y
M
M
M
M
Document type (e.g. passport)
Name verified? Yes  No 
Document number (if applicable)
Date of birth verified? Yes  No 
Document issue date (if applicable) Residential address verified? Yes  No 
Place of issue (if applicable)
Photograph verified? N/A  Yes  No 
Document expiry date
D
D
Y
Y
M
M
M
M
Applicant 2/Guarantor.
Document type (e.g. passport)
Name verified? Yes  No 
Document number (if applicable) Date of birth verified? Yes  No 
Document issue date (if applicable) Residential address verified? Yes  No 
Place of issue (if applicable) Photograph verified? N/A  Yes  No 
Document expiry date
D
D
Y
Y
M
M
M
M
Document type (e.g. passport)
Name verified? Yes  No 
Document number (if applicable)
Date of birth verified? Yes  No 
Document issue date (if applicable) Residential address verified? Yes  No 
Place of issue (if applicable)
Photograph verified? N/A  Yes  No 
Document expiry date
D
D
Y
Y
M
M
M
M
Members Equity Bank Limited ABN 56 070 887 679 AFSL and Australian Credit Licence 229500. 3
Promo code.
Please provide (if applicable)
Additional details.
Does the customer have multiple applications in progress? Yes 
No 
Has the customer sold a property that will settle on or prior to the new purchase? Yes  No 
If yes, please specify the property address below.
State Postcode
Broker declarations.
1. I declare that any information contained in this form is true and correct and obtained directly from the applicant(s).
2. I certify that I have provided the applicants with the Customer Information Pack.
3. I certify that:
– I have interviewed all applicant(s) and any guarantor(s) (if applicable) face-to-face. The required original identification
documents were produced to me and copies of these documents are attached to this form.
– All photographic identification produced and sighted by me is a “reasonable likeness” to the individual(s). Nothing in my dealings
with the individual(s) has raised any suspicions concerning the identification documents.
Broker name Broker signature
ME broker identification number Date
D
D
M
M
Y
Y
Y
Y
BC0007.v04/202008/216698
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Customer identification and broker declarations (face-to-face). (Australian National University)

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Completed 16 October 2020

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