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Senior Trust Retirement Village Income Generator Limited (the Company)

Application Form

This Application Form represents an offer to purchase shares in Senior Trust Retirement Village Income Generator Limited. The terms of the offer are described in the current Product Disclosure Statement posted on this website. You should read the Product Disclosure Statement before you make an application for shares please click here

If you require assistance filling in this Application Form, please call us on Freephone: 0800 609 600.


Please enter names as they appear on your Drivers License or Passport

* required

* required

If this is a joint application please fill in the details below of the second Applicant

Please enter names as they appear on your Drivers License or Passport

  1. To set Date of Birth, click on Calendar icon

  2. In Pop up box click on Year 2022 and scroll up to your birth year and click on it

  3. Click on arrow < or > to change month to your month born

  4. Click on date of month born

  5. You should see your DOB as DD/MM/YYYY

Enter the address for Applicant #2 if it differs from the address above. If it is the same, please leave the fields below blank. 


I wish to purchase shares for the following NZ$ Amount: 

* required

Applications minimum amount you can apply for is $1000.00 and then in multiples of $1000.00 thereafter. 

A separate email will be sent with details for transferring funds to the Senior Trust Bank Account. 

We will call you if you do not have an email. 

Income Generator Applications Account : 02-0108-0504403-000

Quarterly Distributions: Please provide bank details for Dividend Distribution Payments

PLEASE NOTE: No distribution payments will be made by cheque. Payments will be withheld until such time a bank account is provided


I agree to receive my communications via email at my email address provided below:

IRD NUMBER (Both IRD numbers are required in respect of a joint application)

Please advise of country you are a Tax Resident of and Tax Identification Number if available.


Applicant One

Applicant Two


Applicants must provide details of their drivers license which will be used for AML/CFT Act verification purposes along with the DOB and Street address provided above. 

Applicant One

Version Number

Applicant Two

Version Number

If you don't have a driver's licence you can provide some other form of identification such as a copy of a passport.  If you do not provide these details your application form cannot be processed.


By clicking the "submit and logout" button on this Application Form:

  1. 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.

  2. I / We declare that all details and statements made by me / us in this Application Form are complete and accurate.

  3. 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.

  4. 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.

  5. I / We acknowledge that an application cannot be withdrawn or revoked by me / us once it has been submitted.

  6. 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.

  7. You should read the Product Disclosure Statement before you make an application for shares please click here 

The information in this Application Form is provided to enable the Company to process your application, and to administer your investment.  By submitting 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.

* required

Thanks for submitting! We will be in touch via email shortly.

If the above button is greyed out, please ensure all of the fields marked '* required' are filled out correctly. If completed correctly, the button will turn orange

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