Ezybonds
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Certified Membership Application
Please complete and submit the following form. Fields marked with * are mandatory.
 COMPANY DETAILS
1.0 Legal name of your business: *
2.0 Your Ezy ID No: * (Note: this is different from your Security PIN)
3.0 Enter the ID of the Accredited Corporate Manager (ACM) who referred you here? (this may be entered automatically) *
4.0



4.1		 What is your business structure? *

If "Other" then enter below
5.0 Are your shares listed on a stock exchange? Yes No
6.0



6.1		 Registered Address:



Registered Number:
7.0


7.1		 Date of Incorporation or Date Business Commenced: *


Place of incorporation:		 - -

8.0 Business address: *
Address
City
State or Province
Post Code
9.0
Please list all of your directors/partners and their addresses: * (Enter at least one name and address)
Director/Partner 1

 Director/Partner 2
 Director/Partner 3
Director/Partner 4
Director/Partner 5
 Director/Partner 6
 BUSINESS DETAILS
11.0 Choose your business products/services related industry: *
12.0 Provide details of your trading name(s):
13.0 Provide details of your website address(es): *
Note: If no existing web site address please insert "Website to be developed".
14.0 Do you currently accept credit or debit cards?
15.0 How long have you been trading online?
16.0 What is the jurisdiction of your principal place of business? *
17.0 From what jurisdiction(s):
a) Does the majority of your existing customer base derive? *
b) Do you anticipate your potential customer base to derive?


18.0 In which jurisdiction resides the server that:
a) Hosts your website? *
b) Contains your business records?


 OPERATIONAL DETAILS
19.0




19.1


19.2		 Please provide your contact details: Mailing address

Main No.


Fax No.

20.0


20.1		 To whom should documentation be sent? Name

Position
21.0
a

b
21.1


21.2


21.3		 Please provide principal contact details: * First Name

Last Name

Position

Phone

Email
22.0



22.1


22.2


22.3 		Please provide your bank details: Bank Name

Branch address

Account No / IBAN [whichever is applicable]

Sort Code / BSB No / Routing No [whichever is applicable]
AGREEMENT
* Tick here if you have read and agree to the:


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and Data Active Solutions Pty Ltd.
All rights reserved.
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