Shareholder Details

First Name

* Required

Last Name

* Required

Phone Number

Middle Name(s)



Residential Address






Mailing Address







Verification of Identity

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. 


Drivers License

Version Number

Application Amount

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. 


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 I / We acknowledge that an application cannot be withdrawn or revoked by me / us once it has been submitted.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

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.

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