CUSTOMER INFORMATION FORM

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AGM & ELECTION NOTICE

CUSTOMER

INFORMATION FORM

This form is designed to collect information from Members, customers or visitors who visit any Mounties Group venue.

Personal Details

Membership Number: *

Country of Residence *

First Name: *

Country of Citizenship *

Last Name: *

Primary ID presented:

(Primary ID includes driver license, photo card, passport, immi card or birth certificate – see appendix for full list of accepted documents)

Residential Address: *

Expiry Date:

Personal Details

Annual Gross Income *

$0 — $25,000

$25,001 — $50,000

$50,001 — $75,000

$75,001 — $100,000

$100,001 — $150,000

$150,001 — $200,000

$200,001 — $500,000

$500,001 and above

Source of Income *

Salary & Wages (see below)

Superannuation / Pension

Inheritance

Business Earnings (see below)

Centrelink Payments

Legal Settlement

Investments

Trust Income

Gift

Other (please specify)

If other, please describe your source of income:

Occupation:

Industry:

Employment Type:

If Business Earnings is selected as income source, please provide:

Status:

Industry:

ABN:

Address:

Wealth - Please indicate your net worth *

Less than $500,000

$500,001 — $1,000,000

$1,000,001 — $2,500,000

$2,500,0001 - $5,000,000

More than $5,000,000

Source of Wealth (Please select all applicable) *

Business Ownership

Investments

Trust Income

Inheritance

Savings

Gift

Legal Settlement

Other (Please Specify)

If other, please describe your source of wealth:

Member Declaration

1. I declare that all information in this form is complete, accurate and not misleading.

2. I acknowledge and consent to Mounties Group collecting, using and disclosing my personal information provided in this form, or otherwise supplied by me, for the purpose of delivering gaming services and complying with its obligations under the Anti-Money Laundering and Counter-Terrorism Financing Act 2006 (AML/CTF Act), associated regulations and rules. This includes, but is not limited to, identity verification, transaction monitoring and reporting as required by law. I understand that this information will be handled in accordance with Mounties Group’s Privacy Policy and the Australian Privacy Principles.

3. I consent to Mounties Group disclosing the personal information provided in this form to government agencies to comply with applicable laws, regulations and requirements of any applicable regulatory body.

4. I consent to providing any further information or documentation at the request of Mounties Group upon completing this form. I confirm that I have read, understood and agree to be bound by the terms and conditions printed above.

5. I acknowledge that if I do not provide information requested in this form, or if I provide incomplete or false information, Mounties Group may be unable to offer certain services, process my membership, or meet its legal obligations, which may result in the limitation or termination of my membership.

Signature:

Date: *

E-Mail: *

Appendix: Acceptable Identification Documents

Australian

A current driver’s license or learner’s permit issued by an Australian State or Territory Government agency
A current digital driver’s license or learner’s permit issued by an Australian State or Territory Government agency
A current proof of age card issued by an Australian State or Territory Government agency
A current Australian passport or an Australian passport that has expired within the preceding 2 years
A current firearms licence issued by an Australian State or Territory Government agency which includes a photograph
Australian Defence Force identification
A current ImmiCard issued by the Australian Government
A Convention Travel Document or Certificate of Identity Document issued through the Australian Passport Office and including a photograph

Foreign

A current foreign driver’s license issued by a foreign government or foreign government agency which includes a photograph
A current foreign passport issued by a foreign government or the United Nations or an agency of the United Nations which includes a photograph
A current national identity card issued by a foreign government or foreign government agency which includes a photograph

Privacy Statement

Mounties Group is committed to protecting your privacy, keeping your information safe, ensuring the security of your data, allowing you access to our privacy policy and to your personal information. Information on how personal information is collected, used, disclosed, secured and stored can be found on www.mountiesgroup.com.au/about/your-privacy.

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Phone: (02) 9822 3555
Postal Address: 101 Meadows Road, Mount Pritchard, NSW 2170

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