Bambora Merchant Application

Address *

Street Address
Suburb
City	Region
Post Code	Country

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

Clear
Date *

Month Day Year
Date

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

Month Day Year
Email
example@example.com
Position

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

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

Clear
Date

Month Day Year
Date

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

Month Day Year
Email
example@example.com
Position

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

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

Clear
Date

Month Day Year
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

Month Day Year
Email
example@example.com
Position

Residential Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

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

Clear
Date

Month Day Year
Date

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

Month Day Year
Email
example@example.com
Position

Residential Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

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

Clear
Date

Month Day Year
Date

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

Month Day Year
Email
example@example.com
Position

Residential Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

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

Clear
Date

Month Day Year
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 *

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Bambora Terms and Conditions
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