Business enviroment
Independent Business Application and Basic Agreement (IBA)
First Name:
Middle Name:
Surname:
Name Preferred to be known by
National Insurance Number
Your National Insurance Number is used as a unique identifier to track and identify your commission payments
Date of Birth (dd-mm-yyyy):
/
/
Gender:
M
F
These details are used for statistical analysis of Genistar Representatives and to verify the applicant’s right to work in the UK
Nationality
Non-EU/EAA or Swiss Nationals must submit evidence of their right to work in the UK
CURRENT ADDRESS
Address 1:
Address 2:
City:
County:
Postcode
Telephone:
Fax:
Mobile:
Email:
Spouse’s Name:
Spouse’s Email:
APPOINTMENT APPLIED FOR
You are applying for an Appointed Representative position
NOTE: If you have permission under Part IV of the Financial Services and Markets Act 2000 (“FSMA”) to carry on Regulated Activities, or if you are currently registered with the FSA as an Appointed Representative you CANNOT apply to Genistar to be an Appointed
Representative. Details of the Regulated Activities which each type of Representative is permitted to carry out are set out in Clause 2 of the
Basic Agreement
APPLICANT HIERARCHY INFORMATION
Code No Recruiter:
Surname:
This code number is assigned recruit credit
Code No First Upline:
Surname:
This code number is used to build the commission hierarchy
Code No EVP:
Surname:
F0403/05.13
Page 1 of 5
IBA FEE COLLECTION AUTHORISATION
I hereby authorise Genistar Limited to charge my account, indicated below, or accept the attached cheque for the amount of £140 (inclusive of VAT) for the purposes of processing my application and providing training and materials for the competency course.
PLEASE SELECT AND COMPLETE ONE OF THE OPTIONS BELOW FOR PAYING THE £140 IBA FEE
Paying by Cheque
Please make your £140.00 cheque payable to Genistar Limited and attach securely to this paperwork
Paying by Card
Name
First Name:
Middle Name:
Surname:
Name Preferred to be known by
National Insurance Number
Your National Insurance Number is used as a unique identifier to track and identify your commission payments
Date of Birth (dd-mm-yyyy):
/
/
Gender:
M
F
These details are used for statistical analysis of Genistar Representatives and to verify the applicant’s right to work in the UK
Nationality
Non-EU/EAA or Swiss Nationals must submit evidence of their right to work in the UK
CURRENT ADDRESS
Address 1:
Address 2:
City:
County:
Postcode
Telephone:
Fax:
Mobile:
Email:
Spouse’s Name:
Spouse’s Email:
APPOINTMENT APPLIED FOR
You are applying for an Appointed Representative position
NOTE: If you have permission under Part IV of the Financial Services and Markets Act 2000 (“FSMA”) to carry on Regulated Activities, or if you are currently registered with the FSA as an Appointed Representative you CANNOT apply to Genistar to be an Appointed
Representative. Details of the Regulated Activities which each type of Representative is permitted to carry out are set out in Clause 2 of the
Basic Agreement
APPLICANT HIERARCHY INFORMATION
Code No Recruiter:
Surname:
This code number is assigned recruit credit
Code No First Upline:
Surname:
This code number is used to build the commission hierarchy
Code No EVP:
Surname:
F0403/05.13
Page 1 of 5
IBA FEE COLLECTION AUTHORISATION
I hereby authorise Genistar Limited to charge my account, indicated below, or accept the attached cheque for the amount of £140 (inclusive of VAT) for the purposes of processing my application and providing training and materials for the competency course.
PLEASE SELECT AND COMPLETE ONE OF THE OPTIONS BELOW FOR PAYING THE £140 IBA FEE
Paying by Cheque
Please make your £140.00 cheque payable to Genistar Limited and attach securely to this paperwork
Paying by Card
Name