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Introducer Registration Form for the introduction of business to Reparo Finance and Fast Track Business Finance Ltd

pIntroducers must register by completing this form and signing our terms and conditions before any commission can be paid

Business Details

Legal Name

Trading Name

Telephone Number

Fax Number

Email Address

Web Address

Address

PostCode

Type Of Business Sole Proprietor Partnership (inc LLP’s) Limited Company

Company Registration Number

Date of Incorporation

Registered Address

PostCode

Nature of Business Finance Broker Residential Broker Commercial Broker Accountant Financial adviser Other

If other, please specify

VAT Number

Professional standing /major shareholders

a)Been the subject of any investigation, inquiry or regulatory/enforcement action or proceedings involving actual or alleged crime? Yes No

b)Been disqualified from acting as a company director? Yes No

c)Been subject of a receiving order? Yes No

d)Entered into an arrangement with creditors? Yes No

e)Been a director of a company which was wound up and declared bankrupt? Yes No

f)Been the subject of a court judgement for any outstanding debts? Yes No

g)Been convicted of a criminal offence? Yes No

If you have answered ‘Yes’ to any of the above, please give details

Regulatory Compliance

Does your firm have policies and procedures in place designed to prevent and detect all forms of financial crime (fraud, bribery, corruption and money laundering)? Yes No

Do your firm’s staff receive financial crime prevention, fraud, bribery, corruption and money laundering training? Yes No

All Shareholders, Owners, Partners, Directors or Sole Trader

Name

Position

Email Address

Date of birth

Office phone number

Mobile phone number

Home Address

PostCode

How long have you lived at this address?

Previous Address

PostCode

Declaration and Signatures

Introducer Registration DP Statement

Using my personal information

Whether or not this registration is accepted, you may use all the information I give to you, or which you hold on me to register me as an introducer and for the ongoing administration of the registration. You will keep informationabout me and my business after my registration with you ends.

I am responsible for keeping you informed of any changes to my bank account details. I understand you may reject registrations at your discretion without any explanation.

Signature *

What to do next?

Please return this completed form along with details of your bank account number, sort code, branch and name of the bank that you would like your commission to be paid into, along with either a cancelled cheque or paying in slip confirming these details, or a copy bank statement (not showing any transactions).

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Peter House
Oxford Street
Manchester
M1 5AN
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contact@reparofinance.co.uk

0161 521 0870‬