Victorian Consolidated Regulations

Introduction Agents Regulations 1998 - SCHEDULE 1

NOTICE OF INTENTION TO ACT AS AN INTRODUCTION AGENT Introduction Agents Act
1997 Section 15(1)-Notice of Intention to Act as an Introduction Agent You
must lodge this notice if you intend to act as an introduction agent at least
30 days before you begin to act as an introduction agent. Natural persons
should complete Section A of this form. Corporations should complete Section B
of this form. SECTION A-NATURAL PERSONS Please answer the following questions
(circle YES or NO as appropriate)-

   (a)  Are you under 18 years of age? YES/NO

   (b)  Are you an undischarged bankrupt? YES/NO

   (c)  Have you executed a deed of arrangement under Part X of the
        Bankruptcy Act 1966 of the Commonwealth (or corresponding legislation
        in another jurisdiction) where the terms of the deed have not been
        fully complied with? YES/NO

   (d)  Do you have creditors who have accepted a composition under Part X of
        the Bankruptcy Act 1966 of the Commonwealth (or corresponding
        legislation in another jurisdiction) where a final payment has not
        been made under that composition? YES/NO

   (e)  Have you been convicted, within the last 5 years, of an offence
        involving fraud, dishonesty, drug trafficking or violence punishable
        by imprisonment for 3 months or more (regardless of where the offence
        occurred)? YES/NO

   (f)  Are you a represented person within the meaning of the Guardianship
        and Administration Board Act 1986? YES/NO

   (g)  Are you a licensee or an approved manager under the
        Prostitution Control Act 1994? YES/NO

   (h)  Are you the subject of a current order under section 64 of the
        Introduction Agents Act 1997 stopping you from acting as an
        introduction agent? YES/NO

   (i)  Are you the subject of a current order under section 65 of the
        Introduction Agents Act 1997 disqualifying you from acting as an
        introduction agent? YES/NO If you answered "YES" to any of the above,
        section 14 of the Introduction Agents Act 1997 provides that you must
        not act as an introduction agent. Doing so may result in prosecution
        under section 14, with a maximum possible penalty of a fine of $50 000
        or imprisonment for 12 months. If you are able to answer ALL of the
        above in the negative, you may proceed to give notice of your
        intention to act as an introduction agent by completing the following
        details and sending the notice to the address shown at the end of the
        notice. Sch. 1 1. PERSONAL INFORMATION (a) Surname

(b) Given name/s

(c) Date of Birth
	      /      /
(d) Place of Birth

2. IDENTIFICATION Please provide a copy of at least one of the following forms
of identification- (a) current passport; (b) current driver's licence; (c)
full birth certificate or extract of birth; (d) certificate of Australian
citizenship; or (e) marriage certificate.





3. ADDRESSES/TELEPHONE/FACSIMILE (a) Residential Address



Telephone
Facsimile (b) Postal Address



(c) Business Address/es (please provide details of ALL business addresses at
which you intend to act as an introduction agent and telephone and facsimile
numbers for those addresses)



Telephone
Facsimile (Attach separate page if further space needed)

Sch. 1 4. BUSINESS NAMES Please provide- (a) details of ALL business names
which you intend to use while acting as an introduction agent; and (b) a copy
of a certificate of registration under section 23 of the
Business Names Act 1962 for EACH business name Details-







5. PARTNERSHIP DETAILS Please provide the following details of any partners
with whom you act as an introduction agent- (a) Surname

(b) Given name/s

(c) Date of Birth
	      /      /
(d) Place of Birth

(Attach separate page/s for additional partners)

Sch. 1 6. COMMENCEMENT DATE* Date on which you intend to commence acting as an
introduction agent
      /      /


* This date must be at least 30 days after the date on which this notice is
given

SECTION B-CORPORATIONS DETAILS OF PERSON GIVING NOTICE ON BEHALF OF THE
CORPORATION (a) Surname

(b) Given name/s

(c) Date of Birth
	      /      /


(d) Place of Birth

(e) Position Within the Corporation

Please answer the following questions (circle YES or NO as appropriate)-

   (a)  Are any of the corporation's directors disqualified from acting as an
        introduction agent? YES/NO

   (b)  Has the corporation been convicted, within the last 5 years, of an
        offence involving fraud, dishonesty, drug trafficking or violence
        punishable by imprisonment for 3 months or more (regardless of where
        the offence occurred)? YES/NO

   (c)  Is the corporation being wound up? YES/NO

   (d)  Has a receiver or receiver and manager been appointed? YES/NO

   (e)  Is the corporation under official management? YES/NO

   (f)  Has the corporation entered into a compromise or arrangement with
        another person under Chapter 5 of the Corporations Act, the
        administration of which has not concluded? YES/NO

   (g)  Is the corporation the subject of a current order under section 64 of
        the Introduction Agents Act 1997 stopping it from acting as an
        introduction agent? YES/NO

   (h)  Is the corporation the subject of a current order under section 65 of
        the Introduction Agents Act 1997 disqualifying it from acting as an
        introduction agent? YES/NO If you answered "YES" to any of the above,
        section 14 of the Introduction Agents Act 1997 provides that the
        corporation must not act as an introduction agent. Doing so may result
        in prosecution under section 14, with a maximum possible penalty of a
        fine of $50 000. If you are able to answer ALL of the above in the
        negative, you may proceed to give notice of the corporation's
        intention to act as an introduction agent by completing the following
        details and sending the notice to the address shown at the end of the
        notice.

1. CORPORATION'S DETAILS (a) Full name of corporation

(b) Australian Company Number

2. IDENTIFICATION Please provide a copy of the corporation's certificate of
registration

3. ADDRESSES/TELEPHONE/FACSIMILE (a) Address of corporation's registered
office



Telephone
Facsimile (b) Corporation's principal place of business in Victoria



Telephone
Facsimile



(c) Address/es of all other business premises in Victoria at which the
corporation intends to act as an introduction agent



Telephone
Facsimile (Attach separate page if more space needed)

Sch. 1 4. DIRECTORS (a) Please provide the following information for each
director of the corporation
Surname

Other names

Date of birth
	      /      /

Place of birth

Residential address

Residential phone number (Attach separate page/s for additional directors) (b)
Please also provide, for each director, a copy of at least one of the
following forms of identification-

   (i)  current passport;

   (ii) current driver's licence;

   (iii) full birth certificate or extract of birth;

   (iv) certificate of Australian citizenship; or

   (v)  marriage certificate.

5. BUSINESS NAMES Please provide- (a) details of ALL business names which the
corporation intends to use while acting as an introduction agent; and (b) a
copy of a certificate of registration under section 23 of the
Business Names Act 1962 for EACH business name Details-







Sch. 1 6. COMMENCEMENT DATE* Date on which the corporation intends to commence
acting as an introduction agent
      /      /


* This date must be at least 30 days after the date on which this notice is
given __________________