APPLICATION FOR REGISTRATION AS A DEBT AGREEMENT ADMINISTRATOR (COMPANY) Bankruptcy Act 1966 Subsection 186B(2)(a) Privacy The information you are required to provide on this form is collected under, and for the purposes of, the Bankruptcy Act 1966 or related legislation. The Australian Financial Security Authority has a privacy policy at www.afsa.gov.au/privacy that provides information regarding the collection, storage, use and disclosure of personal information, including how you may: (i) access your personal information; (ii) seek to have that information corrected; and (iii) complain if you feel your privacy has been breached, along with information on how your complaint will be dealt with. About This Form This is the prescribed form for completion by applicants who seek to become registered as a debt agreement administrator under Part IX of the Bankruptcy Act. This application should only be made once you have read the document Guidelines and Processes for Registration of Debt Agreement Administrators available from AFSA offices or the AFSA website www.afsa. gov.au. This application can be made only by a person who is duly authorised to make the application on behalf of an Australian registered company. Please note it is a condition of the company s registration that the person or people who have overall management responsibility of the debt agreement operations of the company either be a registered debt agreement administrator or a registered trustee. Each person with overall management responsibility that is not a registered debt agreement administrator or a registered trustee is required to complete a separate Form 24A Application for Registration as a Debt Agreement Administrator (Individual or Person with overall Management Responsibility). Please attach extra pages if required and ensure required attachments (outlined on the last page of this form) are included with your application. Once the information is complete the application can then be submitted either by email, post, or fax to: The Registrations Officer AFSA Regulation PO Box 10443 Adelaide St Brisbane Queensland 4000 Telephone: 07 3360 5404 Fax: 07 3360 5402 Email: registrations.officer@afsa.gov.au If you need help completing this form, contact the Registration Officer, AFSA Regulation on 07 3360 5404. Admin Use Only Date received (DD/MM/YYYY) Date recorded on NPII (DD/MM/YYYY) Amount received Receipt number page 1 of 5
Section 1: Company Applicant Details Position within the company (eg director) Company name ACN ABN Company registered address Date of incorporation (DD/MM/YYYY) Trading name (if any) Section 2: Person/s with Overall Responsibility for the Management of the Company s Debt Agreement Activities Please Note: It will be a condition of the company s registration that the person or people who have overall management responsibility of the debt agreement operations of the company need to either be registered debt agreement administrator(s) or registered trustee(s). Please refer to the document Guidelines and Processes for Registration of Debt Agreement Administrators available from AFSA offices or the AFSA website www.afsa.gov.au for more details on who needs to be nominated in this section. You need to nominate the person/s in this section. Each person with overall management responsibility that is not a registered trustee or registered debt agreement administrator will need to complete separate individual applications. Provision is made for 2 people in this form. If more are involved please copy this and attach additional pages. Person 1 Date of birth (DD/MM/YYYY) Position in corporation (eg director) Is this person a registered debt agreement administrator? No Yes Is this person a registered trustee? No Yes If the answer to these 2 questions is No have they applied for registration? No Yes page 2 of 5
Person 2 Date of birth (DD/MM/YYYY) Position in corporation (eg director) Is this person a registered debt agreement administrator? No Yes Is this person a registered trustee? No Yes If the answer to these 2 questions is No have they applied for registration? No Yes Section 3: Company Director/s Details Managing Director: Director 2: page 3 of 5
Director 3: Director 4: Note: If you wish to register more than 4 directors please attach an additional page with their details. Section 4: General Business Details Professional memberships (if any): organisation and level Do you, your business or company and/or subsidiaries provide any other services apart from administering debt agreements? No Yes If yes, please provide brief details of the other services provided by your business Are you currently administering debt agreements? No Yes If yes, please provide the current number of uncompleted debt agreements Number of people employed or expected to be employed? Do you plan to use agents, consultants or brokers who are not direct employees to assist in preparing proposals? No Yes Trust account Name of financial institution where debt agreement trust account is to be operated Location State page 4 of 5
Business premises main location Postal address Contact number Mobile number Fax number Business email address Attachments Required: Criminal database search for all company directors evidencing that they have not been convicted of an offence involving fraud or dishonesty in the last 10 years before making this application Prescribed application fee enclosed, or arrangements made for payment (provide details of proposed or arranged payment here) Signature Date page 5 of 5