If this is a joint application please fill in the details below of the second Applicant
B. APPLICATION & PAYMENT
I wish to purchase shares for the following NZ$ Amount:
Applications minimum amount you can apply for is $1000.00 and then in multiples of $1000.00 thereafter.
Choose ONE of the PAYMENT options only below. Please tick the box next to your selected option.
for purchase of shares must be accompanied by payment in the correct amount. Option 1: A one-time internet transfer to the following bank account (please use surname as reference); Income Generator Applications Account : 02-0108-0504403-000 Option 2: Please find attached my payment by CHEQUE for the dollar amount of shares applied for above made payable to Senior Trust Retirement Village Income Generator” and crossed "Not Transferable PLEASE NOTE: No distribution payments will be made cheque. Payments will be withheld until such time a bank account is provided C. COMMON SHAREHOLDER NUMBER (CSN)
If you have a CSN for any other securities you hold which is in the exact same name as this application, please enter it here. If you do not have a CSN, leave the space blank and you will be allocated a CSN and Authorisation Code (FIN) when your Units are allotted
D. ELECTRONIC COMMUNICATIONS
I agree to receive my communications via email at my email address provided below:
E. IRD NUMBER (Both IRD numbers are required in respect of a joint application) Please tick this box if you hold an RWT exemption certificate from the IRD and attach a copy of your RWT exemption certificate. Please tick this box if you are a non- resident for NZ tax purposes; under the Income Tax Act 2007, you will be treated as a NZ tax resident unless this box is ticked. Please tick this box if you are a US resident, citizen or taxpayer. APPLICABLE PRESCRIBED INVESTOR RATE (TICK ONE BOX) F. VERIFICATION OF YOUR IDENTIFY
All applicants must provide details of their drivers licence which will be used for AML/CFT Act verification purposes along with your DOB and Street address provided in “A” of this application form.
If you don't have a driver's licence you can provide some other form of identification such as a copy of a passport or a copy of a birth certificate. If you do not provide these details your application form cannot be processed.
TERMS AND CONDITIONS
By signing this Application Form:
I / We agree to subscribe for shares upon and subject to the terms and conditions of this Application Form and I / we agree to be bound by the provisions thereof.
I / We declare that all details and statements made by me / us in this Application Form are complete and accurate.
I / We certify that, where information is provided by me / us in this Application Form about another person, I / we are authorised by such person to disclose the information to you and to give authorisation.
I/We consent to the Company verifying my/our identity electronically using my/our details provided above and below by providing those details to a credit reporting agency or any other person or entity for the sole purpose of identity verification.
I / We acknowledge that an application cannot be withdrawn or revoked by me / us once it has been submitted.
I / We acknowledge that the Offer is only made in New Zealand, and by applying for shares, I / we agree to indemnify the Company and its respective directors, officers, employees and agents in respect of any liability incurred by the Company as a result of my / our breach of securities laws in any jurisdiction other than New Zealand.
The information in this Application Form is provided to enable the Company to process your application, and to administer your investment. By signing this Application Form, you authorise the Company to disclose information in situations where the Company are required or permitted to do so by any applicable law or by a governmental, judicial or regulatory entity or authority in any jurisdiction. If you are an individual under the Privacy Act 1993, you have the right to access and correct any of your personal information.
I have read the Product Disclosure Statement and accept the Terms and Condions. Submit