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Residential Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Postal Address

(If different to above)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Tax Residence of Other Countries *

To enable us to comply with Australian Tax Law, we are required to confirm all account holders tax residency. If you are a tax resident of another country, we will contact you and you will need to complete a Self-Certification form and provide us with your Taxpayer Identification Number (TIN).

I am a tax resident of Australia only

I am NOT a tax resident of Australia

Consent to Electronic Identification *

We are required under the Anti-Money Laundering and Counter-Terrorism Financing Act, to collect and verify information relating to your identity. Subject to your consent, we will disclose your name, address and date of birth to external organisations in order to electronically match your information with information on their databases. These organisations will assess and advise us whether all or some of the information you provided matches their records. We have an arrangement with Equifax Pty Ltd who completes electronic verification on our behalf. The external data sources used to verify your identity include: • Credit information files held by Equifax Pty Ltd (this is only to confirm your identity and is not a credit check) • Publicly available information such as the electoral roll and white pages • Information held by the official record holder via third party systems. We will share your personal information with the following external organisations for the purpose of verifying your identity; • Equifax Pty Ltd • The Australian Government’s Document Verification Service (DVS) If you do not wish Broken Hill Bank to provide your personal information to the external organisations listed above we will not be able to verify your identity electronically. Please contact Broken Hill Bank on (08) 8088 2199 for information on alternative ways we can verify your identity. Further information about how we collect and handle personal information is available in our Privacy Policy located on our website www.brokenhill.bank

I confirm that I am authorised to provide the personal details presented and I consent to my information being checked with the document issuer or official record holder via third party systems and services for the purpose of confirming my identity.

About You: Questions to help us get to know you and how you use your accounts.

How will you use your Broken Hill Bank account?

(select all that apply)

To receive wages/investment income

To pay for purchases, utilities etc

To borrow money for personal real estate

To build up savings and wealth

To borrow money for purchases or asset investment

To receive business earnings and make payments

To pay for overseas purchases

Do you intend on using this account to trade in/invest in cryptocurrency?

Please Note: Broken Hill Bank does not provide accounts for this purpose and, if identified, these accounts will be closed

Yes

No

What category best describes credits to your account?

(select all that apply)

Income (e.g. salary)

Government benefits

Compensation or other settlements

Family inheritance

Income for business

Investment income (e.g. property, shares)

Gift/donation or windfall

What type of accounts will you require?

Savings account

Transaction account

Fixed Term Deposit

Loan

If you are changing from another bank, why have you changed?

(select all that apply)

Not happy with service

Fees & Charges

Scam or fraud activity

Bank imposed restrictions

Other

What made you choose to open an account with Broken Hill Bank?

(select all that apply)

Advertising

Referral

Products

Face-to-face service

Branch facilities

Other

Please register me to receive the latest news and offers by email *

Yes

No

Would you like to receive notice of Broken Hill Bank Annual General Meeting? *

Yes

No