BUYER APPOINTMENT OF AGENT
This form allows you to appoint a person as an “Agent” to select a Block and execute and exchange a First Grant Contract
for you on your behalf.
The Territory treats your right to privacy seriously and all personal information it collects is held in accordance with the
requirements of the Information Privacy Act 2014.
For further information please see the Privacy Policy on the LDA website.
Please complete all required fields in BLOCK LETTERS.
Sales Event & Date The full name(s) and address(es) of the Applicant(s).
If the applicant is a company, proceed directly to next page.
Applicant 1
a
Title
First name
Middle name
Last name
Address
State
Postcode
b
Form of identification - For Office Use Only - A copy of this identification must accompany this form.
Driver’s licence
number
State
Other (Medicare
or passport number)
Applicant 2
a
Title
First name
Middle name
Last name
Address
State
Postcode
b
Form of identification - For Office Use Only - A copy of this identification must accompany this form.
Driver’s licence
number
Other (Medicare
or passport number)
Form Continues Overleaf
State
BUYER APPOINTMENT OF AGENT
Where Company, please state:
Company name
ACN
Hereby appoint:
c
Agent’s details :
First name
Middle name
Last name
Address
State
Phone
Postcode
Mobile
Facsimile
d
Email
e
Form of identification - For Office Use Only - A copy of this identification must accompany this form.
Driver’s licence
number
State
Other (Medicare
or passport number)
The Applicant(s) appoints the Agent as my/our Agent to select a block and to execute a First Grant Contract for that
block.
I/We agree to be liable for all actions of the Agent including in respect of any decisions by the Agent during the sales event,
any subsequent execution and exchange of a First Grant Contract by the Agent and to indemnify the Territory in relation to
any loss or damage as a result of the actions of the Agent.
f
Date
D D
M M Y Y
f
Date
D D
M M Y Y
Date
D D
M M Y Y
Signature of Applicant 1
Position in Company
(if applicable)
Signature of Applicant 2
Position in Company
(if applicable)
I agree to accept my appointment as Agent of the Applicant(s)
Signature of Agent 1
g
Notes:
a) The full name(s) and address(es) of the Applicant(s) to be inserted.
b) A photocopy of the identification of the Applicant(s) must be submitted with the Buyer Appointment of Agent Form.
c) The full name and address of the Agent to be inserted.
d) Email address included on the Buyer Appointment of Agent Form must be valid and working to receive information from
the Territory. It is the responsibility of the Applicant(s) and/or the Agent to notify the Territory if the email address has
changed.
e) Original Identification must be available for checking at exchange of contracts.
f) All Applicants must sign the Buyer Appointment of Agent Form. Applicants signing on behalf of a company are required to
state their position in the company (Director, Secretary, Manager etc.). The number of authorised signatories required in
accordance with the constitution of the company must sign the Buyer Appointment of Agent Form.
g) The Agent must sign the Buyer Appointment of Agent Form.