Bambora Merchant Application

Director 2 (only required if applicable)
Director 2 Name
Birth Date

MonthDayYear
Email
example@example.com
Position
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Shareholder
Percentage Ownership
NZ Drivers License / Passport Number
NZ License Version Number / Passport Expiry Date
DECLARATION SIGNATURES
Signature:

Clear
Date

MonthDayYear
Date

Director 3 (only required if applicable)
Director 3 Name
Birth Date

MonthDayYear
Email
example@example.com
Position
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Shareholder
Percentage Ownership
NZ Drivers License / Passport Number
NZ License Version Number / Passport Expiry Date
DECLARATION SIGNATURES
Signature:

Clear
Date

MonthDayYear
Date

INDIVIDUAL SHAREHOLDER
SHAREHOLDER 1

Please provide details for all controlling individual stakeholders. Not required if already provided as a Director.

SHAREHOLDER 1 (only required if applicable)
Shareholder 1 Name
Birth Date

MonthDayYear
Email
example@example.com
Position
Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Shareholder
Percentage Ownership
NZ Drivers License / Passport Number
NZ License Version Number / Passport Expiry Date
DECLARATION SIGNATURES
Signature:

Clear
Date

MonthDayYear
Date

SHAREHOLDER 2 (only required if applicable)
Shareholder 2 Name
Birth Date

MonthDayYear
Email
example@example.com
Position
Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Shareholder
Percentage Ownership
NZ Drivers License / Passport Number
NZ License Version Number / Passport Expiry Date
DECLARATION SIGNATURES
Signature:

Clear
Date

MonthDayYear
Date

SHAREHOLDER 3 (only required if applicable)
Shareholder 3 Name
Birth Date

MonthDayYear
Email
example@example.com
Position
Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Shareholder
Percentage Ownership
NZ Drivers License / Passport Number
NZ License Version Number / Passport Expiry Date
DECLARATION SIGNATURES
Signature:

Clear
Date

MonthDayYear
Date
DIRECT DEBIT AUTHORITY

Please print following direct debit authority, fill out required fields and upload below to complete Bambora Merchant Application

Bambora Direct Debit Authority
Upload Signed Copy of Direct Debit*

Browse Files

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Bambora Terms and Conditions
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