application for a brokerage contract to act as … · application for a brokerage contract to act...

APPLICATION FOR A BROKERAGE CONTRACT TO ACT AS INTERMEDIARY

1. OFFICE USE ONLY

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FG number

F G

Consultant

2. IMPORTANT NOTES

1.Fedgroup comprises of the following entities:1.1 Fedgroup Participation Bond Managers Pty Ltd1.2 Fedgroup Life Limited Ltd1.3 Fedgroup Trust Administrators Pty Ltd1.4 Fedgroup Fund Administrators Pty Ltd 1.5 Fedgroup Asset Management Pty Ltd1.6 Fedgroup Employee Benefits Pty Ltd1.7 Fedgroup Financial Services Pty Ltd

2. “Brokerage” refers to the entity that has been registered as FSP in terms of FAIS (company, firm, etc)3. “Financial Planner” refers to a broker giving advice

3. PARTICULARS OF BROKERAGE

Type of business

Company Close Corporation Sole Proprietor Partnership

Registered name of business

Nature of business

Registration number (if applicable)

Physical address Postal address

Code Code

Full name/s

3A. BROKERAGE PRINCIPAL

Title Initials Surname

ID or passport number Date of birth

DDGender

FMMM YY YYDesignation

89 Bute Lane, Sandton. PO Box 782823, Sandton, 2146. T 011 305 2323 E [email protected] W fedgroup.co.za

Initial

Fedgroup Asset Management Pty Ltd (Reg. No. 1997/007878/07) Auth FSP. 665, License 13B: No. 24/536Fedgroup Life Ltd (Reg. No. 2007/018003/06) Auth FSP. 40607Fedgroup Employee Benefits Pty Ltd (Reg. No. 2008/013532/07) License 13B: No. 24/493Fedgroup Trust Administrators Pty Ltd (Reg. No. 1951/003389/07) Auth FSP. 16302, License 13B: No. 24/505

Fedgroup Participation Bond Managers Pty Ltd (Reg. No. 1956/001143/07) CIS 804Fedgroup Financial Services Pty Ltd (Reg. No. 2012/000697/07) Auth FSP. 45563Fedgroup Fund Administrators Pty Ltd (Reg. No. 1990/002515/07) Auth FSP. 45563 FSP: 26/10/6690

Email

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DDGender


Cell number

Brokerage Income Tax number

Tel number

FSP registration number

VAT number

Email

Cell number

Tel number

Residential Address

VAT number

Full name/s



DDGender


Email

Cell number

Tel number

Residential address

VAT number

Full name/s



3A. BROKERAGE PRINCIPAL (CONTINUED)

3B. DIRECTOR

3C. DIRECTOR

Initial



5. WHERE APPLICABLE, ATTACH THE FOLLOWING DOCUMENTS

6. PLEASE INDICATE WHICH PRODUCT YOU WOULD LIKE TO MARKET

Please tick the appropriate box

Secured Investment Fiduciary Services Distinction Umbrella

Fund Administration Asset Management

Group Risk Funeral Product Linked Investment Products Critical illness Product

Disability Product

Copy of the FAIS license (including conditios and restrictions)

Copy of the VAT registration certificate and Income Tax Certificate

Copies of Broker principle and each Directors (ID Document, proof of residence)

Copy of proof of bank account (not older than three months)

Utility bill for brokerage not older than 3 months

Copy of notice of registered office and postal address bearing stamp of registrar companies

Most recent certificate of incorporation bearing stamp of registrar of companies

RE1 & RE5 certificate of KI

Designation

Email

Full name/s


ID number Contact number

4. CONTACT PERSON DETAILS (PERSON WITH WHOM FEDGROUP MUST COMMUNICATE)

Tax clearance certificate

Name of account holder

Name of bank Account no

Branch name Branch no

7. BANKING DETAILS (FOR COMMISSION PAYMENTS)

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Beneficiary Care Education Product Bonds

CIS Products Retirement Annuity

8. AUTHORISATION AND DECLARTION (ON BEHALF OF THE BROKERAGE)

1. The brokerage authorises Fedgroup to obtain information from third parties to ascertain the brokerage's fit and proper status, also of its key individuals and representatives.

2. It is acknowledged that the brokerage is not authorised to canvass business for Fedgroup until such time that the brokerage has received an approval to act as Fedgroup intermediary letter. Should the brokerage canvass any business prematurely, Fedgroup will at its own discretion decide whether or not the brokerage should receive payment for such business.

3. It is agreed that, should Fedgroup enter into a brokerage contract with the brokerage, this application will form part of such contract.

4. It is declared and agreed that the agreement shall be dealt with in terms of the contract with regards to any suspension or termination, should any of the following occur: - Any of the information provided on behalf of the brokerage to Fedgroup Financial Services is incorrect and/or incomplete - Fedgroup enters into a brokerage contract with the brokerage and the brokerage subsequently neglects, or fails to inform and provide Fedgroup with full details under the following circumstances: - An additional financial planner is appointed by the brokerage - A financial planner terminates his or her services with the brokerage - There are changes with regards to the business or the board, members and/or shareholders pertaining to the brokerage - The brokerage’s business address changes - The brokerage’s financial services provider licence is suspended and/or not renewed - Any changes that occur to any of the brokerage’s key individuals and representatives

5. I agree that my contractual relationship with Fedgroup Employee Benefits will be subject to South African law and regulation (including but not limited to Financial Intelligence Control Act, Exchange Control and tax requirements.

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9. BROKERAGE PRINCIPAL/DIRECTOR/SHAREHOLDER/KEY INDIVIDUAL

Name and surname

in my capacity as

(place)at

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Brokerage principal/sole proprietor signature Date

DD MM YY YY

Key individual signature

Or

Or

Date

DD MM YY YY

Director/shareholder Date

DD MM YY YY

Type of account

TransmissionCurrent Savings

Commission remittance/statement to be emailed to, if different to contact person

7. BANKING DETAILS (FOR COMMISSION PAYMENTS)

Initial



Email

Full name/s and surname

Contact number Contact number

Email



Email



10. SHAREHOLDERS

Information RequiredA list of shareholders who hold 25% or more of the company’s shares and the percentage of shares held by each such shareholder.

Verification (provide certified copies of the documents listed in this column)Share certificates or a share register in respect of shareholders holding 25% or more of the shares or voting rights in the client.

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Shareholder 1

Shareholder 2

Shareholder 3

Email



Shareholder 4

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11. SHAREHOLDERS

11A. A NATURAL PERSON

Information RequiredPlease provide the following information where applicable – where the above-listed shareholder is:

A certified copy of the person’s green bar-coded ID document, valid SA driver’s license (or valid passport if foreign).


DD MM YY YY

Full name/s

Physical address Nationality (if not South African)

Code

11B. A PRIVATE COMPANY OR CLOSE CORPORATION (FOREIGN OR LOCAL):

Most recent certificate of incorporation and notice of registered office and postal address, bearing the stamp of the Register of Companies and signed by the company secretary.

Proof of business address such as a utility bill, bank statement or similar document (not older than three months).

Registered name of business

Trade name


Registered address Business address

Code Code

11D. TRUST

The trust deed or other founding document in terms of which the trust is created.

Name of the trust

Trust number

Trust’s address

Code

11E. OTHER ENTITY:

The constitution or other founding document in terms of which the legal person is created.

Proof of business address such as a utility bill, bank statement or similar document (not older than three months).

Name of the legal person

Its legal form

Address from which it operates

Code

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11C. PARTNERSHIP

The partnership agreement in terms of which the partnership was formed.


Registered address

Code

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Date

DD MM YY YY

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11F. DECLARATION

We confirm that the above information is true and correct to the best of our knowledge and belief, and enclose copies of the requested verification documentation.

Signed

(Client name)

(authorised signatory

who warrants his/her authority) on behalf of

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