Customer Identification – Authorised Referee

Customer Identification Form Authorised RefereeHBAA302 CUA 05/18 Page 1 of 2 Issued by HSBC Bank Australia Limited ABN 48 006 434 162 AFSL 232595 Complete the form using blue or black pen and print in clear CAPITAL LETTERSC ontinued over pagePART A INDIVIDUAL TO COMPLETEA pplicant s signatureAccount/Application reference numberYOUR SIGNATURE MUST BE WITNESSED BY THE Authorised REFEREED eclarationI 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 nameWork addressPostcodeThis form will be used to verify your identity only where an individual cannot attend an HSBC branch.

Customer Identification Form – Authorised Referee Issued by HSBC Bank Australia Limited ABN 48 006 434 162 AFSL 232595 HBAA302CUA 05/18 Page 1 of 2 Complete the form using blue or black pen and print in clear CAPITAL LETTERS

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  Identification, Customer, Referee, Authorised, Customer identification authorised referee, Customer identification, Authorised referee

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