GoEscrow Forms

A. Personal Details

First Name

Last Name

Date Of Birth

Email Address

Mobile Phone

Unit Number (optional)

Street Number

Street Name

Suburb

State

Post Code

Country

B. Identification

Would you like an SMS sent to your mobile phone for a quick ID document scan?

Yes, send me the SMS No, I will enter identification below

FILL IN ONE OPTION BELOW

Please provide one identification set below. Contact GoEscrow if you do not possess one of these options.

Drivers Licence

Issuing State

Licence Number

Card Number

Expiry Date

Driver licence help

Select the issuing state/territory to see where to find the Licence Number and Card Number.

Passport

First Name

Middle Name (If it appears on passport)

Last Name

Document / Passport Number

Nationality

Place of Birth (optional)

Date of Issue

Date of Expiry

Gender on passport (optional)

Medicare Card

Card Colour

Green Blue Yellow

IRN

Name (exactly) as on card

Medicare Card Number

Expiry Date (MM/YYYY)

The IRN is the number next to the name on the front of the Medicare card. View example Medicare card

Centrelink Card

Centrelink Card Type

HCC Health Care Card PCC Pensioner Concession Card SHC Senior Health Care Card

Customer Reference Number (CRN)

Name on Centrelink card

Expiry Date

Immigration Card

ImmiCard Type

AMS Australian Migration Status EIS Evidence Of Immigration Status PRE Permanent Residence Evidence RDI Residence Determination

ImmiCard No (Card Number)

Expiry Date

Given Name(s) (exactly as on card)

Surname (exactly as on card)

VEVO (Visa check)

Given Name(s)

Surname

Passport Number

Passport Country of Issue

NOTES: The Dept Of Home Affairs Visa Entitlement Verification Online (VEVO) system allows visa holders to clarify residency, work rights, study rights and immigration status in Australia. Persons registered with VEVO may open a GoEscrow Account.

C. Personal Bank Details

When acting as a seller or when receiving refunds we will settle money to your personal bank account. You may provide your information here now, or it can be collected later if needed.

Account Name

Bank/Institution Name

BSB

Account Number

PayID (optional)

SWIFT (optional)

Bank account name should closely match the individual's name. GoEscrow may remit a $0.01 transfer and request a transaction reference code as confirmation. SWIFT codes are required for international bank accounts. Further details may be requested for international settlements. A PayID must match the company and will be used for instant settlements where possible.

D. Source of Funds / OCDD

Do you anticipate participating in escrow transactions above $25,000.00?

Yes No

For transactions above this limit, GoEscrow may ask for a Source of Funds Declaration. You may complete this now, but it is currently optional.

What types of transactions do you expect to use GoEscrow for?

Used Goods Registered Vehicle Resale Machinery/equipment Tradie Style Services Renovation/building Projects Major Construction Professional services Business sale Marine/aviation Domain/digital asset Intellectual Property Transfer High-value goods Executed Contract Facility Warranty and Guarantee Leins Property Sale Deposits Property Liens Replacement of Lawyer Trust Functions Other

Please specify other

Typical transaction value range

Where does the money typically used for GoEscrow transactions originate from?

Salary/wages Personal savings Business income Sale of property Sale of vehicle, goods or equipment Sale of shares/investments Bank loan or finance Private loan Gift from family or another person Inheritance Superannuation/pension Insurance payout Legal settlement A digital asset sale Overseas transfer Cash savings/deposit Other

Please specify other

Will any third party provide funds?

Are any funds expected to come from overseas?

Are any funds expected to come from cash deposits or cryptocurrency/digital assets?

How have you mainly accumulated your overall wealth or financial position?

Employment income Business ownership Property ownership/sales Investments Inheritance/family wealth Superannuation Professional practice income Farming/agricultural income Other

Please specify other

Approximate annual income band

Are you involved in politics?

Do you represent another person/entity?

Any bankruptcy, insolvency, freezing order or similar restriction?

Anything unusual about the source of funds GoEscrow should know?

E. Authority and Execution

I authorise GoEscrow Pty Ltd ACN 650 709 354 to create an account in my name. I am the person in the identification data in section B and I consent to my information being checked with the document issuer or official records holder via third party systems for the purpose of confirming my identity. I have read, understood and agree to the Terms Of Use Agreement and have read and understood the Product Disclosure Statement and Financial Services Guide.

First Name

Last Name

I confirm I am the applicant I confirm the information supplied is true, accurate and complete. Digital signature acknowledgement.