Agent Application – Climax Group

Name

Country Trading

Trading as Company or Individual

Address Line 1

Address Line 2

City

Country

Agencies held

Mobile Telephone

E-mail address

Website

Years IFA (on/offshore)

Client profile outline (Please list countries where clients are based)

Approximate FUM/Number of clients

Preferred Providers

Relevant qualifications

Company

Contact

Phone no. / E-mail address

Company

Contact

Phone no. / E-mail address

Have you or your company ever been convicted of any offenses other than minor motoring offenses in any country?

Yes

Are you or your company the subject of any criminal or civil proceedings in any country?

Yes

Have any legal proceedings been bought against you or your company in any country regarding financial services?

Yes

Have you at any time been refused or had revoked any membership to any professional body or association?

Yes

Have you or your company ever been declared bankrupt or are subject to bankruptcy proceedings in any country?

Yes

Have you or your company ever been investigated by any agency regarding advice given in conjunction with financial services?

Yes

Have you or your company ever been disqualified from any country for actions regarding financial advice?

Yes

This declaration is to be signed by the individual applying for terms of business.

I declare that the information supplied by me in this questionnaire is complete and correct to the best of my knowledge.

I authorize CLIMAX Administration Ltd to approach the aforementioned referees to obtain any information regarding my character and reputation.

I authorize CLIMAX Administration Ltd to share this information with its affiliated companies.

Name