Appointment of an Authorised Representative

ECOPOST PTY LTD

If you wish to appoint an Authorised Representative to deal with Ecopost Pty ltd on your behalf, please complete the form below.

Please note

When you appoint an Authorised Representative you are giving the person you appoint the authority to deal with us on your behalf as your agent. This means that the Authorised Representative has the power to act and access information as if they were you. This includes making complaints, changing account details or terminating a contract. You can of course specify limitations of your Authorised Representative’s rights.

Please note that only account holders can appoint an Authorised Representative. If you wish to appoint more than one Authorised Representative, please complete one Authorised Representative Form for each person you wish to appoint. You can appoint up to three Authorised Representatives.

For security reasons we require you to submit the completed Authorised Representative Form to us as a signed original and witnessed by one of the following persons below:

• A Justice of the Peace;

• An Accountant who is a member of the Australian Institute of Chartered Accountants, CPA Australia or the National Institute of Accountants with 2 or more years of continuous membership;

• A Solicitor or Barrister;

• A Police Officer;

• An agent in charge of, or a permanent employee (with 2 or more years of continuous service) of an Australia Post outlet;

• An officer with, or authorised representative of, a holder of an Australian Financial Services Licence, having 2 or more continuous years of service with one or more licensees;

• A Dentist;

• A Pharmacist;

• A Medical Practitioner;

• A Chiropractor or a Physiotherapist.

Please contact us on 1300 13 4638 if this proves too difficult or inconvenient for you, and we will work with you to find an alternative way of appointing an Authorised Representative.

Appointment of Authorised Representative

Your details:

Account number:

___________________________________________________________________

Account holder’s full name (note: you must be the account holder to appoint an Authorised Representative):

___________________________________________________________________

“I wish to appoint the following person as my Authorised Representative”:

Your Authorised Representative’s details

Authorised Representative’s full name:

____________________________________________________________________

Authorised Representative’s telephone number:

____________________________________________________________________

Authorised Representative’s email address (if applicable):

____________________________________________________________________

Authorised Representative’s physical address:

____________________________________________________________________

Limitations of the Authorised Representative’s rights (Specify anything that your Authorised Representative should NOT be allowed to do on your behalf. If left blank, the Authorised Representative has the power to act as if they were you.):

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Appointment declaration:

“I, ___________________________________________________, authorise Ecopost Pty ltd to deal with the above person as my Authorised Representative. I acknowledge that I am responsible for all acts of my Authorised Representative within the authority as described in this Appointment. Ecopost Pty ltd may assume that it is dealing with the Authorised Representative if they identify themselves as such when contacted at any of the contact numbers/addresses above. This appointment continues until I revoke it in writing.”

Signature:

Place and date:

____________________________________________________________________

Account holder’s signature:

____________________________________________________________________

Witness’s declaration and signature:

“I confirm that the person signing above (account holder) has produced evidence of their identity.”

Place and date:

____________________________________________________________________

Witness’s signature:

____________________________________________________________________

Witness’s full name:

____________________________________________________________________

Witness’s capacity (JP, police officer etc.) and address:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________