Customer Identification – Authorised Referee

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Customer Identification Form Authorised RefereeHBAA302CUA 05/18 Page 1 of 2Issued by HSBC Bank Australia Limited ABN 48 006 434 162 AFSL 232595Complete the form using blue or black pen and print in clear CAPITAL LETTERSContinued over pagePART A INDIVIDUAL TO COMPLETEApplicant s signatureAccount/Application reference numberYOUR SIGNATURE must BE WITNESSED BY THE Authorised REFEREEDeclarationI declare that the information contained above is true and correct and has been completed by me and not any other MM YYCurrent residential address (cannot be a PO Box)CountryPostcodeSuburbStateCityNation ality(if not Australian, nationality must be verified via a foreign passport or foreign national identity card )DD MM YYDate of birthFirst nameTitleLast nameMiddle namePART B Authorised Referee TO COMPLETEWork phone number( )Employer s nameIdentity documents sightedWrite name + Identification number (if any) + date/place/office of nameTitleLast

Page 2 of 2 PART B – AUTHORISED REFEREE TO COMPLETE continued Authorised Referee’s signature THE AUTHORISED REFEREE MUST SIGN, DATE AND …

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