asterisks (*) indicates mandatory fields Proposed Fund Name * Postal Address * Contact Name * Telephone (H) * Telephone (W) Mobile Fax Email * MEMBER AND/OR INDIVIDUAL TRUSTEES Individuals Title Full Name Address DOB Is the person a member? NoYes Is the person a trustee? NoYes Title Full Name Address DOB Is the person a member? NoYes Is the person a trustee? NoYes Would you like us to set up the company? NoYes (If yes please provide preferred company name.) Corporate Trustee (if applicable) Company Name Registered Address ACN/ABN/TFN Director 1 Place of Birth Director 1 Occupation Director 2 Place of Birth Director 2 Occupation NB:All members must be directors and all directors must be members. No member is allowed to be an employee of another member unless they are related. Eligibility for Trusteeship Are all trustees/directors eligible to hold the position of trustee/director in accordance with SIS Act Sec 120? NoYes An individual is not eligible if: (a)At any time: (i) the individual was convicted of an offence (in respect of dishonest conduct) against or arising out of law of the Commonwealth, State, a Territory or a foreign country; or (ii) a civil penalty order was made in relation to the person; or (b) the person is an insolvent under administration. Continuing Administration Superannuation Services Pty Ltd is to be appointed administrator for this SMSF. Authority to Proceed Please proceed with the SMSF set-up. We/I have been supplied with Superannuation Services Pty Ltd fee schedule. We/I understand that Superannuation Services Pty Ltd is not a licensed investment advisor and has not provided any investment advice in relation to setting up this SMSF. Trustee/Director Signature Trustee/Director Signature Referred by Phone
