Onboarding and AML Form Step 1 of 6 16% Personal Information - Privacy Statement We collect personal information from you, including information about: your name your contact information your responses to this form We collect your personal information in order to onboard you as a client (or as a contact of a client – for example a Family Trust or a Company) of our practice and/or update your information from time to time. Please complete this form If you’re new to Paul Gallagher Legal or haven’t dealt with us since 1 July 2018. You have the right to ask for a copy of any personal information we hold about you, and to ask for it to be corrected if you think it is wrong. If you’d like to ask for a copy of your information, or to have it corrected, please contact us at info@lawfirm.co.nz, or 09 415 9321 or at Unit 15A, 65 Paul Matthews Road, North Harbour. Please also note: We need your IRD number. Please have it available to enter in the form. If there is another person or there are people also onboarding our practice with you, we need that person or people to each complete this form. Depending on the nature of the work you want us to do for you, we may need to receive from you further information, including verifying your identity. This is under our mandated Customer Due Diligence requirements under the Anti-Money Laundering and Countering Financing of Terrorism Act 2009. Once you have completed and submitted this form, you and we will receive by email a copy of the questions and your answers and responses. If you need to take a break from the form you can do so, by clicking the Save and Continue Later link at the bottom of each page and you will receive an email with a link to allow you to resume where you left off. Your answers will all be saved automatically. Your DetailsExisting Paul Gallagher Legal Client Account number (if applicable) Is there a separate identity or organisation (such as a Trust or Company) which is or will be our client, and for which you are a contact (such as a Trustee, Shareholder or Director)? Yes No Please name the identity or organisation here. Is there another person or are there other people also onboarding our practice as a client or contact(s)? Yes No Please name them here. Note they will also need to complete and submit their own form.First NameMiddle NameLast Name Add Remove Your DetailsTitle:(Required) Mr Mrs Miss Ms Other Gender(Required) Male Female Non-Binary First Name(Required) Middle Name(s) Surname(Required) Date of Birth(Required) DD slash MM slash YYYY Occupation Daytime Phone Mobile Email address(Required) Current home address: (please note we cannot accept a P.O. Box number)Current Address Street Address Address Line 2 City Region Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Have you lived at this address for more than two years? Yes No If no, please enter your previous address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Is your Mailing Address different from your current home address Yes No If Yes, please enter your current mailing address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country IRD Number(Required) What is your tax rate? Please note that if you don’t advise us your tax rate we will deduct tax at 39% on any investments made through our on-call account, and you will be liable for any under-paid tax. 10.5% 17.5% 30% 33% 39% Non-Resident withholding Tax Are you a New Zealand Resident? Yes No If no, what is your country of residence? AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Declaration of Foreign Citizenship or Residency for tax purposesAre you a US Citizen? Yes No Are you a tax resident in a country other than New Zealand? Yes No Please list all countries other than New Zealand in which you are a tax resident and provide the Tax Information Number (T.I.N) for each country Client Name Country Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. AML InformationHave we asked you to provide us with information relating to our obligations under the Anti-Money Laundering and Countering Financing of Terrorism Act 2009? Yes No We will need to verify your identity from the following Options. Please note that although you will be asked to scan and upload copies of the relevant document(s) we will also need to see the originals when you visit us. By providing copies you will reduce the time needed by both you and us to complete our statutory obligations. If you have concerns that you are not able to provide us with the necessary identification and/or you are unable to visit us, please let us know and we can help with obtaining what you might require or provide an alternative process. Option 1 - One of the Following NZ Passport NZ Firearms Licence Overseas Passport NZ Certificate of identity Emergency Travel Document NZ Refugee Travel Documentation National Identity card Option 2 – Two of the following types of ID NZ Driver’s Licence (must be current) AND ONE OF Credit /Debit/Eftpos Card for a NZ registered bank (with name embossed) Bank statement from a NZ registered bank NZ Government Department or Agency correspondence (e.g. WINZ, IRD) Option 3 – Two of the following types of ID One of the following NZ Driver’s Licence (must be current) Hospitality NZ 18+ card Current International driving permit AND one of the following NZ Birth Certificate NZ Citizenship Certificate Overseas Birth Certificate Overseas Citizenship Certificate Please select the Option you wish to use to verify your identity Option 1 Option 2 Option 3 Option 1Please select which document you using for identification verification; NZ Passport NZ Firearms License Overseas Passport NZ Certificate of Identity NZ Refugee Travel Documentation Emergency Travel Document National Identity Card Please scan and upload the copy here; Drop files here or Select files Max. file size: 24 MB, Max. files: 2. Option 2Please select which of the following documents you using for identification verification; Credit /Debit/Eftpos Card for a NZ registered bank (with name embossed) Bank statement from a NZ registered bank NZ Government Department or Agency correspondence (e.g. WINZ, IRD) Please scan and upload copies of both the NZ Driver’s Licence and the other selected document here; Drop files here or Select files Max. file size: 24 MB, Max. files: 4. Option 3Please select which of the following documents you are using for identification verification; NZ Driver’s Licence (must be current) Hospitality NZ 18+ card Current International driving permit AND which of the following documents you are using for identification verification; NZ Birth Certificate NZ Citizenship Certificate Overseas Birth Certificate Overseas Citizenship Certificate Please scan and upload both the selected documents here: Drop files here or Select files Max. file size: 24 MB, Max. files: 4. Client Authority/DeclarationThe Information you provide to Paul Gallagher Legal will be kept strictly confidential and will be securely held by Paul Gallagher Legal. You have a right to access the information by enquiring at our office and you may also request that is be correct. A fee may be payable. So Paul Gallagher Legal can ensure your information is accurate, please let us know of any changes in your personal details (like a change of address). Paul Gallagher Legal may use this information to: Administer, manage and monitor any services that we provide to you; Meet our obligations under the Anti-Money Laundering and Countering Financing of Terrorism Act and associated Regulations; Conduct market research, data processing and statistical analysis; and Unless you disagree, provide you with information about updates in law or other services that we can offer you. I do not wish to receive information about other services. Consent(Required) I agree to the following declarationPaul Gallagher Legal may disclose information about you for the above purposes. I declare that; The information in the application forms the basis of the agreement between Paul Gallagher Legal and me. I certify that the information on this form is true and correct. I certify that I am not an undischarged bankrupt and am not liable under proceedings under the insolvency Act 1967 and its amendments. Date DD slash MM slash YYYY What happens next?If you have any concerns or issues relating to completing this form, please feel free to contact us directly or you can use the following field to outline those matters.Once you have completed and submitted this form, you and we will receive by email a copy of the questions and your answers/responses. Important. If you have completed the AML section (Step 5) and uploaded copies of identity verification documents we will still need to sight the originals of those documents when you visit us. NameThis field is for validation purposes and should be left unchanged. Tell us How We Can Help You Have a chat to one of the team to see how we can provide you with advice and expertise in your legal matter. Contact Us Here