(leave blank if the investment is in one individual's name)
(Please list the names of Trustees, Directors and individuals for a joint investment below if the investment is for a Trust or Company)
Advisor Name:
(* = compulsory fields)
______________________________________________________
Title*
First Names:*
Surname:*
Date of Birth:*
IRD Number:*
Evidence of Identity:
Upload evidence of Identity here:*
* Please sign the copy of your ID before you upload it
Title
First Names:
Surname:
Date of Birth:
IRD Number:
Upload evidence of Identity here:
Relationship to Investors: (Please specify)
Is the address for service via your Advisor? yes
Contact Address:*
Home Phone:*
Business Phone:*
Fax:
Mobile:
Email:* (Information about your investment will be sent to the email you enter here)
In the case of a joint application, please use the applicant with the highest PIR. IRD Number:* Prescribed Investor Rate (PIR): Click here to learn how to calculate your PIR
(See page 8 of the Investment Statement for information on the funds)
Diversified Wealth Management BALANCED Fund Diversified Wealth Management DYNAMIC Fund
Single investment (minimum $2,000): $
Regular investment amount: (minimum of $200 per month): $ Regular investment start date: (dd/mm/yy)
Regular withdrawal amount: $ Regular withdrawal amount start date: (dd/mm/yy)
Please upload a printed bank deposit slip for verification of which is required as redemptions must be paid into your nominated account:
Option1: Please make your cheque payable to: Diversified Nominees Ltd, PO Box 105142 Auckland 1143
Option2: Payment by Direct Deposit. Application money to be deposited into the bank account: Diversified Nominees Ltd, Account Number: 03-0104-0121894-00
Please download a Direct Debit Authority form here
(all boxes must be ticked “I agree” in order for the application to be successful)
THE PRIVACY ACT: This statement relates to the personal information you are providing The Manager by way of this application and any subsequent personal information which you may provide in the future. The personal information you have supplied may be used by the Manager and the Trustee (and related entities thereof) for the purposes of enabling the manager to arrange and manage your investment, and to contact you in relation to your investment. The Manager will provide you (on request) with the name and address of any entity to which information has been disclosed. You have the right to access all personal information held about you by the Manager. If any of the information is incorrect, you have the right to have it corrected. You acknowledge that you are authorised to provide personal information on behalf of the applicant and evidence of this authority is provided (in the case of a parent/guardian/other providing information about the applicant). You agree that your/each of your names and addresses may be used by Diversified Wealth Management Ltd to provide you with newsletters and other information about the fund and other products and services.
I agree
EMAIL USE: I consent to receiving financial statements, and other documents which the Trustee or the Manager are required to send me electronically at the email address son this form, or another email address supplied to the Manager.
Click here to download The Diversified Wealth Management Ltd Investment Statement *
DECLARATION: I/We have downloaded, read and retained a copy of the Investment Statement dated 15 March 2011 and agree to be bound by the terms and conditions of the Trust Deed. I/We agree to the terms outlined above in relation to the Privacy Act and the supply of personal information. I/We understand that the fund is for long term investing and is liable to fluctuations and may rise and fall from time to time. I/We understand the manner in which the fees will be deducted from the fund.
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