I confirm that prior to completing this application, I understand the entity’s obligations under the Act, and the
Financial Markets Supervisors Regulations 2014, and I have read and understood the Guidance Note: Supervisor
Licensing issued by the Financial Markets Authority.
I confirm (please tick those statements that are applicable):
Debt securities and/or Registered Schemes
The applicant is currently registered under the Financial Service Providers (Registration
and Dispute Resolution) Act 2008.
The applicant, being an applicant for a licence that covers a retirement village, is compliant
with section 13 (a) of the Financial Service Providers (Registration and Dispute
Resolution) Act 2008.
I, _______________ _______________ _______________, of __________________________________________
solemnly and sincerely declare the following:
that I have been authorised to act on behalf of the applicant in this application
that having conducted all necessary enquiries, I declare the information provided in this form to be true
and correct to the best of my knowledge.
Signature of person making declaration
Declared at this day of 20
e and designation of person to take statutory declaration
(Note: If you are making this declaration outside New Zealand, please ensure it is sworn in
accordance with section 11 of the Oaths and Declarations Act 1957).
- Page 3 of 5 -
Please initial here