MORTGAGE MART LMG EXPRESS ACCREDITATION FORM

Section 1 - Aggregation

My Aggregator is (please tick)*

Please ensure this is accurate as commissions are paid via the aggregator noted.

CHOICE

FAST

PLAN

LMG

Section 2 - Broker details (Name as per photo identification)

First Name*

Last Name*

Previously known names

Date of Birth*

Email Address*

Mobile Phone*

Office Number

Trading Name*

Trading ABN*

Office Address (Address where you are predominantly based)*

Office Address Suburb*

Office Address State*

Office Address Post Code*

Section 3 - NCCP details

Broker - CRN or ACL Holder*

Credit Representative Number

Australian Credit Licence

Do you have a minimum of 2 year credit/lending experience?

Yes

Section 4 - Introduced By

Broker - Referred By*

Section 5 - Personal Identifier

The following information is required specifically for identity authentication purposes (i.e. To confirm caller identity prior to releasing confidential information) You must take reasonable measures to keep the nominated identifier confidential.

Identifying Question*

Identifying Answer*

Section 6 - Broker Declaration and Acknowledgement
Have you ever:

Declared Bankruptcy, been declared Bankrupt, or been subject to control under the Bankruptcy Act 1966?*

Yes

Been found guilty of, or been charged with any crime or offence (other than a minor crime such as a traffic offence) which has not been withdrawn or dismissed?*

Yes

Had an application for grant or renewal of any financial services licence or registration, authorisation to act as a credit representative or membership of an industry or professional association refused or revoked?*

Yes

Had an application for accreditation declined or been cancelled by any other credit provider?*

Yes

Been banned from holding a company directorship?*

Yes

Been known by or had any other name?*

Yes

If you have answered yes to any of section 6, please provide full details:

I acknowledge that:

This application for accreditation will be assessed by Mortgage Mart ("MM") and that approval of this accreditation is at the discretion of MM. MM will notify me of the outcome of this application within 10 working days upon receipt of this fully completed application and all supporting documentation as required;
If approved, this application for accreditation will grant me accreditation and access to Mortgage Mart product offerings;
Approval of my 'new' accreditation is subject to the completion of broker induction training as required;
If my accreditation is terminated, MM may report full details of the reasons for termination (including for dishonesty or fraud) and provide copies of relevant documents, to any Approved Industry Association and/or any governing body which regulates or supervises the conduct of mortgage brokers and I will not hold MM liable for such reporting.

By submitting this statement you agree to the following:

Mortgage Mart- terms and conditions, and privacy.