Third Party Authority Form (non-CFS accounts)

Dear Sir/Madam Third Party Authority
Full Client Name:
Fund Name:
Account Number:
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Address

I wish to advise that I have appointed Paul Melling & Associates Pty Limited to act as my representative in obtaining any information or forms they may request in connection with my policies with your company.

Company/Adviser/Administration:	Paul Melling & Associates Pty Limited,
	Chrissy Jones, Kirsty Rae, Larissa Stratton, Ed Agius, Nimali Barfoot, Genevive Santiago, Ellie Pacete

Address:	Suite 1 486 Lower Heidelberg Road
	Heidelberg Vic 3084

Phone:	03 9450 5000

Dealer Group:	Paul Melling & Associates Pty Limited
ABN:	99 006 425 092

AFS Licence:	231247

Your assistance on this matter would be highly appreciated. Should you require any further information please do not hesitate to contact Paul Melling & Associates Pty Limited on 03 9450 5000.

Thank you.

Yours Sincerely,

Please attach a copy of your certified ID

Cancelof
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Should be Empty: