Tyro EFTPOS Banking Application Form

Company (Australian or Foreign)

We thank you for your interest in Tyro’s financial products. A.F.C.2018.04.09

This application is for the ‘Tyro EFTPOS Banking’ product which comprises of both:
• Tyro EFTPOS facility, and
• Tyro Smart Account, a fee-free interest bearing business transaction account.

Who must complete this form:

Authorised Signatories: If the company has 2 or more office bearers, at least 2 directors; or 1 director and 1 company
secretary

Beneficial Owners: Each person who ultimately controls or owns 25% or more of the company. If no such person, the
person who is entitled to exercise (whether directly or indirectly) 25% or more of the company’s voting rights (including
a power of veto) or any person who holds the position of senior managing official, such as a Chief Executive Officer (or
equivalent). Control of a company can be by means of trusts, agreements or practices, including through the capacity
to determine decisions about financial and operating policies of the company. If the company is listed on a registered
exchange or licensed by ASIC or APRA, the beneficial owner details are not required.

Please ensure that you have submitted the following:

Completed application form (this form)

Copy of Driver Licence or Passport of each Director/Secretary who signs in the Application Acknowledgement
section.
• The copy must be clear, legible and contain a signature (a certified copy may be requested)
• Signatures on the application form must match the signature(s) on Driver Licence or Passport
(For example, if you have changed your name, proof of change must be provided)

Copy of Account Statement for Linked Account (or Welcome Letter if bank account newly opened) (See Direct Debit
Request Section 8)
• Must be within the last 3 months
• Account must be in the “same legal name” as the entity applying in Section 1

If your business has an annual card revenue of more than $50m

Copy of your latest audited financials

If you are filling in this form electronically, please Save your progress periodically by going to File > Save (Shortcut: Ctrl +S).

Where to send this form and supporting documents once completed:

First name Last name

Salesperson

By email

By mail Sales, Tyro Payments, Level 1, 155 Clarence St, Sydney NSW 2000
 A.F.C.2018.04.09

Tyro EFTPOS Banking Application Form - Company (Australian & Foreign)

1 Company Details
Legal Name of Company (as registered with ASIC) Registered Office Address (as registered with ASIC) (No PO Box)
MAALAKSHMI PROPRIETARY LIMITED 338 MCDONALDS ROAD

Registered Business Name / Trading Name Suburb SOUTH MORANG State VIC Postcode 3752

Principal Place of Business (No PO Box)

ABN Business Phone number
6 7 6 3 3 8 6 0 7 2 3
Suburb State Postcode
ARBN (if foreign) Country where established
Delivery Address (No PO Box) - Address where the EFTPOS terminal(s)
will be delivered if different from Principal Place of Business

Business Description (please be as specific as possible)

Suburb State Postcode

Full Name of each Director (if company is registered as Pty Ltd)

HEMA BASSI

2 Tax Obligations and CRS/FATCA Declaration

Select the CRS & FATCA entity type. C. Is the Company incorporated in the U.S.?
For definitions of Foreign Tax terminology, please refer to
No Yes
www.tyro.com/definitions-crs-fatca/

A. Common Reporting Standard (CRS) D. Is the Company a tax resident of a country other than
Australia?
What category is the Company? (Select one)
Other Active Non-Financial Entity (NFE) that is if: No: please go to Question E.
1. less than 50% of the entity’s gross income
consisted of Passive Income; and Yes: please provide details for all jurisdictions in which
2. less than 50% of the assets held by the entity were the Company is a resident for tax purposes.
used to produce Passive Income
Note: Passive income includes dividends, interest, rents Country of Tax Residence 1
and royalties, annuities
Passive Non-Financial Entity (NFE)
(that is Not an Other Active NFE)
Taxpayer Identification Number (TIN) 1

Related Entity of a Listed Corporation TIN unavailable:

Other (i.e. Listed Corporation, Financial Institution,

Governmental Entity, International Organisation,
Central Bank)
Country of Tax Residence 2

Taxpayer Identification Number (TIN) 2

(Please list the category that applies)
TIN unavailable:
B. Foreign Account Tax Compliance Act (FATCA)
What category is the Company? (Select one)
Active Non-Financial Foreign Entity (NFFE) that is if:
If any ‘TIN unavailable’ box is checked, please
1. less than 50% of the entity’s gross income
consisted of Passive Income; and
provide an explanation.
2. less than 50% of the assets held by the entity were
used to produce Passive Income
Note: Passive income includes dividends, interest, rents
and royalties, annuities
Passive Non-Financial Foreign Entity (NFFE) I/We certify the tax residence country/countries
(that is Not an Active NFFE) E.
provided represents all countries in which the
Company is considered a tax resident.
Other (i.e. Financial Institution or Non-participating
Financial Institution)

(Please list the category that applies)

Tyro Payments Limited ABN 49 103 575 042 AFSL 471951 Page 2/9
 A.F.C.2018.04.09

3 Administration Authority and Authorised Signatories

Authorised Signatory Administration Authority

An Authorised Signatory will be able to:
•• Authorise changes and generally control your
Tyro EFTPOS Banking
•• Access the Tyro App which allows you to activate and
manage the Tyro Smart Account. By activating the Tyro
Smart Account, via the Tyro App, you will be able to:
•• initiate and approve payments; and
•• accept loan offers from Tyro (if eligible).
Your Administration Authority will be “Any to sign”
unless you request us to change it to “Any two to sign”. This
will be important when/if you (or any Authorised Signatory)
activate your Tyro Smart Account.
For more information about the Administration Authority, see
the Tyro EFTPOS Banking Terms and Conditions at tyro.com.

4 Authorised Signatories Details

Director (Authorised Signatory 1)

Your Overseas Tax Obligations/Information

Director
Complete this section only if:
Are you a Beneficial Owner that owns or Yes No • the Company is declared as a Passive NFE/NFFE
controls 25% or more of the Company? in section 2
and
• you are a Beneficial Owner who owns or
Full Name (as displayed on your Identification Documents) controls 25% or more of the Company
HEMA BASSI
A. Are you a U.S. citizen? No Yes
Email (must differ from other Authorised Signatory)
B. Are you a tax resident of a country other than Australia?
No: please go to Question C.
Mobile Number (must differ from other Authorised Signatory)
Yes: please provide details for all jurisdictions in which
you are a resident for tax purposes.
Country of Tax Residence 1
Residential Address
35 PLOWMAN CT

Taxpayer Identification Number (TIN) 1

Suburb EPPING State VIC Postcode 3076
TIN unavailable:
Country of Residence Date of Birth

D
1 D
2 M
1M0 Y
1 Y
9 Y
7 Y5
Country of Tax Residence 2
Please provide details of at least TWO of the following:
Australian Driver Licence No. Expiry Date
Taxpayer Identification Number (TIN) 2
D D MM Y Y Y Y
TIN unavailable:
Medicare Card No. Reference Expiry Date

MM Y Y Y Y If any ‘TIN unavailable’ box is checked, please

provide an explanation.
Passport Number Expiry Date

D D MM Y Y Y Y
Country Issued I certify the tax residence country/countries
A certified copy of your C.
provided represents all countries in which I am
identification document(s) may
be required.
considered a tax resident.

EFTPOS Administrator

Authorised Signatory 1 will be the EFTPOS Administrator. Complete below if you want to nominate a different
EFTPOS Administrator
An EFTPOS Administrator is able to: Full Name Mobile Phone Number
•• manage the EFTPOS facility using the Merchant Portal
•• view transaction reports, fees and charges
•• manage additional Merchant Portal users Email

Tyro Payments Limited ABN 49 103 575 042 AFSL 471951 Page 3/9
 A.F.C.2018.04.09

Director or Company Secretary (Authorised Signatory 2)

Your Overseas Tax Obligations/Information

Director Company Secretary
Complete this section only if:
Are you a Beneficial Owner that owns or Yes No • the Company is declared as a Passive NFE/NFFE
controls 25% or more of the Company? in section 2
and
• you are a Beneficial Owner who owns or
Full Name (as displayed on your Identification Documents) controls 25% or more of the Company

A. Are you a U.S. citizen? No Yes

Email (must differ from other Authorised Signatory)
B. Are you a tax resident of a country other than Australia?
No: please go to Question C.
Mobile Number (must differ from other Authorised Signatory)
Yes: please provide details for all jurisdictions in which
you are a resident for tax purposes.
Country of Tax Residence 1
Residential Address

Taxpayer Identification Number (TIN) 1

Suburb State Postcode
TIN unavailable:
Country of Residence Date of Birth

D D MM Y Y Y Y Country of Tax Residence 2

Please provide details of at least TWO of the following:
Australian Driver Licence No. Expiry Date
Taxpayer Identification Number (TIN) 2
D D MM Y Y Y Y
TIN unavailable:
Medicare Card No. Reference Expiry Date

MM Y Y Y Y If any ‘TIN unavailable’ box is checked, please

provide an explanation.
Passport Number Expiry Date

D D MM Y Y Y Y
Country Issued I certify the tax residence country/countries
A certified copy of your C.
provided represents all countries in which I am
identification document(s) may
be required.
considered a tax resident.

Continue on next page

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 A.F.C.2018.04.09

5 Price Schedule - Simple Pricing

Note: All fees and charges are quoted exclusive of GST.

Tyro Merchant Service Fee (MSF) Additional Payment Methods

For each transaction, you pay to us:
Enable acceptance of AMEX/JCB
Visa/MasterCard
by Direct Settlement
Domestic Consumer Credit Card %
0.900% with Tyro %
%
American Express Terms and Conditions apply and are available
Domestic Premium & Commercial Card %
1.710% at www.tyro.com/american-express.

International Card* %
2.360% using AMEX Merchant Number
AMEX Merchant Number
Domestic Consumer Debit Card %
$0.255

MasterCard Micropayments equal to or $0.255 You may choose this if you already have an agreement with AMEX.
less than $15

UnionPay Enable acceptance of Diners Club

International Card %
2.230% Diners Club Merchant Number

eftpos Debit Card

$15 or more transactions $
$0.284
Enable Dynamic Currency Conversion (DCC)
Less than $15 transactions $
$0.284
Are you registered for GST? Yes No
Cash-out $
$0.00
(Payable to you by Tyro -
DCC Rebate
for international transactions
Tap & Save $
N/A processed using DCC)

Enable Tap & Save (for eftpos transactions)**

* Visa/Mastercard international transactions incur an International Service Fee
(currently 0.40%)
** Where you opt-in for Tap & Save, where possible, cardholder eftpos
transactions are routed through eftpos instead of Visa/Mastercard. Terms and
Conditions and some exclusions apply. For further information, refer to Tyro.com.
MOTO (Mail Order / Telephone Order)
MOTO transactions allow merchants to take card-not-
present transactions over the phone or from mail orders.
MOTO transactions are riskier than other transactions and
are more likely to result in a chargeback or fraud. In the
event of a chargeback, it is the merchant’s responsibility to
prove the actual cardholder authorised the transaction.

Other Tyro Fees (Payable to Tyro in addition to the MSF)
Visa/Mastercard card-not-present
MOTO Fee (transactions processed over the
phone or mail order)
Currently The risk of MOTO transactions resides with the
merchant, not the bank/acquirer or the cardholder. For
further information about MOTO transactions refer to
0.15% tyro.com/terms-and-conditions and Tyro’s Chargebacks
and Disputes Guide at tyro.com/chargebacks.

Would you like to activate MOTO? Yes No

Payable to Tyro where you have a
separate agreement with AMEX, If yes, how many of your card payments, on average, will be
JCB and Diners Club and our taken over the phone or mail order?
Switching only obligation in relation to a
0.10%
Fee Transaction is to transmit the <10% 10% 20% 30% 40% 50% +
particulars of the Transaction to the
Scheme operator under which the
Card was issued.
Annual Card Revenue
<$5m <$10m <$50m $50m+

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 A.F.C.2018.04.09

6 EFTPOS Terminals
Note: All fees and charges are quoted exclusive of GST.
Model Quantity Health Fund Claiming Quantity

Desktop - Yomani $
$29.00 per terminal, per month N/A Will incur an additional CSC service fee for
claiming access to health funds
$
Handheld - Yoximo $39.00 per terminal, per month N/A ($10 per terminal, per month)

Name displayed on EFTPOS receipt*

The monthly rental fee starts no later than 7 days after shipping and includes
Merchant Portal access, support, and maintenance. Non-returned terminals are
charged at replacement cost.
*Defaults to business name if not specified (21 characters)

7 Your Tyro Smart Account

As part of this application, you will receive a fee-free business transaction account called the Tyro Smart Account which you can
activate at any time. Your EFTPOS funds will be initially deposited here and then automatically transferred into the Linked Account
you nominate below. You don’t need to do anything further unless you want to activate your Tyro Smart Account.

You can find out about the benefits of activating the Tyro Smart Account here tyro.com/smart-account/

8 Direct Debit Request for Linked Account

By signing this Direct Debit Request (DDR) you request and authorise Tyro Payments Limited ABN 49 103 575 042 (User ID 166111)
(the Debit User) to debit/credit the account below (the Linked Account) with fees, charges and any other amount due to Tyro under
the Tyro EFTPOS Banking Terms and Conditions (“Terms”) through BECS in accordance with this Authority and the Direct Debit
Request Service Agreement contained in the Terms.

Tyro Smart Account

Whilst the Tyro Smart Account is not activated the Linked Account will be:
•• The Settlement Account where Tyro will credit settlement proceeds and debit any refunds or chargebacks from your Tyro
EFTPOS Facility
•• The Fee Account which Tyro will debit for all Tyro fees, charges and other amounts due to Tyro under the Terms (unless another
Fee Account is nominated).

If the Tyro Smart Account is activated, then:

•• The Tyro Smart Account becomes the Settlement Account
•• The Tyro Smart Account becomes the Fee Account (unless another Fee Account is nominated)
•• The Linked Account will be debited for any fees, charges and other amounts due to Tyro under the Terms only if they cannot be
debited from the Tyro Smart Account (or other nominated Fee Account)
•• The Linked Account is used for transfers in/out of the Tyro Smart Account using the Tyro App

Please provide Linked Account details

Linked Account Name

Must be in the same legal name as section 1 BSB Number Account Number
MAALAKSHMI PROPRIETARY LIMITED

If the account below has two or more signatories, Optional text to appear on bank statements
two must sign.

Linked Account Signatory 1 (Full Name) Linked Account Signatory 2 (Full Name)
Must be at least one Authorised Signatory from section 4 Must be at least one Authorised Signatory from section 4

HEMA BASSI

Signature (Digital signatures not accepted) Date Signed Signature (Digital signatures not accepted) Date Signed

SIGN HERE D D MM Y Y Y Y SIGN HERE D D MM Y Y Y Y

Tyro Payments Limited ABN 49 103 575 042 AFSL 471951 Page 6/9
 A.F.C.2018.04.09

If you are filling in this form electronically, please Save your progress periodically by going to File > Save (Shortcut: Ctrl +S).

9 Application Acknowledgement (If the Company has two or more office bearers, two must sign)

Merchant Declaration
1. I/We declare that I/we have accessed, read and understood the Tyro EFTPOS Banking Terms and Conditions (”Terms”) which are available at www.
tyro.com and agree to be bound by the Terms and any variation of the Terms.
2. I/We authorise each source (including a credit reporting body, bank or financial institution) to give Tyro any information about the applicant
which Tyro requires for this Application and I/we release Tyro and each source from liability for, and indemnify Tyro and each source against, all
claims and losses arising out of disclosures made in the course of such inquiries. For avoidance of doubt, the signing of this Application by the
Merchant does not signify agreement by Tyro.
3. I/We consent to the collection, use and disclosure of personal information and credit information by Tyro in accordance with the Privacy
Statement & Consent and Tyro’s Privacy Policy and where I/we have provided information about, or on behalf of, the account holder or another
individual (including any beneficial owners) in this Application Form, I/we represent and warrant that I/we have obtained the express informed
consent from that individual:
a) to the collection, use and disclosure of that individual’s personal and credit information by Tyro in accordance with the Privacy Statement
& Consent and Tyro’s Privacy Policy; and
b) for Tyro to use that individual’s personal information for the purposes of performing a verification of the identification of that individual in
accordance with the Privacy Statement & Consent, as required under the Anti-Money Laundering and Counter-Terrorism Financing Act 2006
(Cth).
4. I/We wish for Tyro to contact me/us using any of the contact details in this form (or as otherwise notified to Tyro) in relation to any existing or
new products and features. If I/we later change my/our mind and no longer wish to be contacted, I/we will notify Tyro accordingly via email at
marketing@tyro.com.
5. I/We acknowledge that all payments from my/our Tyro EFTPOS facility will be credited to my/our Tyro Smart Account. Where my/our Tyro
Smart Account is not my/our nominated Settlement Account I/we instruct Tyro to transfer all funds from my/our Tyro Smart Account to my /
our nominated Settlement Account on a daily basis. In the case where I/we do not have access to the Tyro App, I/we instruct Tyro to transfer all
funds from my/our Tyro Smart Account to my/our nominated Linked Account on a daily basis.
6. I/We declare that I am/we are authorised to provide this information on behalf of the account holder and/or beneficial owners (as applicable)
and understand (and have made the account holder and beneficial owners aware) that the information provided in this form may be reported
to the ATO and exchanged with tax authorities of another country in which the account holder and/or beneficial owners (as applicable) may be
tax resident pursuant to intergovernmental agreements to exchange financial account information.
7. I/We undertake to notify Tyro within 30 days of any change in circumstances that would cause the information in this form to be incorrect or
incomplete (including in relation to the tax residency status of the account holder and/or beneficial owners, as applicable) and to provide Tyro
with an updated self-certification form reflecting these changes.
8. I/We declare that all information provided in this form is, to the best of my/our knowledge and belief, true and correct.
9. By signing below, each signatory consents to Tyro obtaining consumer credit reporting information about that person from a credit reporting
body for the purposes of assessing this Application (as commercial credit is provided as part of the services provided by Tyro) in respect of
any loan request made (whether now or in the future), managing any commercial credit provided and collecting payments that are overdue
in relation to commercial credit provided. Tyro may also obtain commercial credit reporting information on the entity (which may include all
officeholders) periodically. See the Privacy Statement and Consent for further information.

Authorised Signatory 1 Authorised Signatory 2

Full Name Full Name
HEMA BASSI

Signature (Digital signatures not accepted) Signature (Digital signatures not accepted)

SIGN HERE SIGN HERE

Note: Signature must match with signature on Driver Licence or Passport. Note: Signature must match with signature on Driver Licence or Passport.

Date signed Date signed

D D MM Y Y Y Y D D MM Y Y Y Y
I have provided a copy of my Driver Licence or Passport I have provided a copy of my Driver Licence or Passport

Applications are subject to assessment and approval by Tyro.

Office use only: Notes Office use only: Channel Office use only: ISO Agent

Back office Rate Code Promotion Group Merchant ID

Tyro Payments Limited ABN 49 103 575 042 AFSL 471951 Page 7/9
Privacy Statement & Consent
Tyro Payments Limited ABN 49 103 575 042 (“Tyro”, “we”, “us”) is an APP entity
and credit provider for the purposes of the Privacy Act 1988 (Cth) (“Privacy Act”).
Tyro’s Privacy Policy
Tyro’s Privacy Policy sets out detailed information about how, why and
when personal information and credit related personal information (“credit
information”) is collected, disclosed, used, stored and otherwise handled by Tyro.
Tyro’s Privacy Policy is available at www.tyro.com/privacy-policy/. Hard copy is
available on request.
This Privacy Statement & Consent, together with Tyro’s Privacy Policy, sets out:
• purposes for which Tyro collects your personal or credit information;
• consequences if you don’t provide your personal or credit information to
Tyro;
• third parties which Tyro discloses your personal or credit information;
• how to access and seek correction of your personal or credit information;
• how to complain about a breach of Tyro’s obligations in respect of your
personal or credit information and how Tyro will deal with a complaint;
• whether your personal or credit information is likely to be disclosed by Tyro
to overseas entities and in which countries these entities reside;
• information about credit reporting, including the credit reporting bodies
(“CRBs”) to which Tyro may disclose your personal or credit information; and
• matters associated with credit reporting that must be notified to you in
accordance with the Privacy Act.
Purposes of collection of personal and credit information
Tyro collects, holds, uses and discloses personal and credit information for the
following purposes, in addition to any purposes set out in Tyro’s Privacy Policy:
• direct marketing activities (excluding credit eligibility information);
• performing reference checks (including personal references) and conducting
background enquiries;
• verifying any information provided by you to Tyro (including identification);
• reporting payment defaults to CRBs; and
• any other purpose necessary to process an application for services, facilities
or any other arrangement with Tyro.
By agreeing to this Privacy Statement and Consent you consent to Tyro using
your personal and credit information for the purposes set out above, including
using your full name, address and date of birth (“DOB”) for the purposes of direct
marketing activities.
You may withdraw your consent to receive direct marketing communications from
Tyro at any time by using the opt-out-option provided in each direct marketing
communication or you may ask us at any time to include you on Tyro’s “No
contact” list.
Exchange of personal and credit information
Tyro may disclose and/or collect your personal or credit information from the
following entities, in addition to any entities set out in Tyro’s Privacy Policy:
• CRBs, such as Equifax (see below);
• banks or financial institutions;
• referees provided to Tyro;
• government bodies; and
• other third parties.
By agreeing to this Privacy Statement and Consent you:
• authorise each source (including a credit reporting body, bank or financial
institution) to give Tyro any information about you which Tyro requires for
your application; and
• release Tyro and each source from liability for, and indemnify Tyro and each
source against, all claims and losses arising out of disclosures made in the
course of such inquiries.
Overseas disclosures
Tyro discloses personal information to overseas third parties located in the United
States of America and Singapore (each an “Overseas Recipient”) that provide
product analytic services and services and products for storage of personal
information to allow Tyro to conduct its direct marketing activities. Tyro has made
reasonable investigations to ensure that these Overseas Recipients are reputable
service providers.
Once disclosed to an Overseas Recipient, your personal information will be dealt
with in accordance with that Overseas Recipient’s privacy policy. You should be
aware that the Overseas Recipient may not be subject to any privacy obligations
or other principles similar to the Privacy Act. However, Tyro has made reasonable
endeavours to bind the Overseas Recipient to comply with the Privacy Act in
relation to your personal information.
By agreeing to this Privacy Statement and Consent you:
• consent to Tyro disclosing your personal information, such as full name,
address and DOB to an Overseas Recipient that provides product analytic
services and services and products for storage of personal information to
Tyro to conduct its direct marketing activities;
• you will not be able to seek redress under the Privacy Act if the Overseas
Recipient handles the personal information disclosed to it in a way that
breaches the Privacy Act; and
• Tyro will not be accountable under the Privacy Act for any mishandling of the
personal information, provided by Tyro, to the Overseas Recipient.
You may withdraw your consent to disclosures of your personal information by
Tyro to the Overseas Recipients at any time by providing written notice to Tyro.
Tyro Payments Limited ABN 49 103 575 042 AFSL 471951
A.F.C.2018.04.09
However, Tyro will not be able to provide its services/products to you.
Exchange of credit information with credit reporting bodies
In order to assess an application made by you, Tyro may obtain both consumer
and commercial credit reporting information about you from a CRB in relation to
any consumer or commercial credit which may be provided under that application.
Any consumer or commercial credit reporting information collected by Tyro may
be disclosed to any of the entities set out above for the purposes of processing an
application.
For the purposes of providing and managing commercial credit, Tyro may disclose
your personal and credit information to CRBs for the purposes of undertaking a
credit check in relation to an application made by you, for review purposes, for
the purposes of assessing your eligibility for Tyro products or for the purposes of
disclosing payment default information or a serious credit infringement in relation
to commercial credit provided to you. We may disclose information to or collect
information from the following CRBs whose privacy policy and contact details are
at:
• Equifax Australia – www.equifax.com.au or 13 8332
This CRB may include any of your personal or credit information (including
payment default information), disclosed to it by Tyro, in reports provided to other
credit providers to assist other credit providers to assess your credit worthiness.
You may access a copy of the CRB’s policy about its management of credit
information on its website. You have the right to make a request to the CRB not to
use or disclose your credit reporting information:
• for the purposes of pre-screening of direct marketing by a credit provider; or
• if you believe on reasonable grounds that you have been, or are likely to be,
a victim of fraud.
Tyro’s policy about the management of credit information is set out in Tyro’s
Privacy Policy. In accordance with Tyro’s Privacy Policy, you may request to access
or correct your credit information and to make a complaint to Tyro.
AML/CTF – verification of identification
Tyro has obligations under the Anti-Money Laundering and Counter-Terrorism
Financing Act 2006 (Cth) (“AML Act”) in relation to collecting personal information
and verifying that information for the purpose of verifying the identity of its
customers and the beneficial owners of its customers. Tyro may satisfy these
verification obligations using the following methods:
• document-based verification; or
• electronic verification through the Document Verification Service (“DVS”)
(which can be accessed through a third party gateway service provider).
For the purposes of verifying the identity of an individual using the above methods,
Tyro may disclose an individual’s name, residential address, DOB, driver licence
number, passport number and/or Australian citizenship certificate number to
a CRB or other third party gateway service provider (“service provider”). The
information disclosed by Tyro will be matched with information held by the
document issuer or official record holder, using third party systems, for the
purpose of confirming the identity of the individual. The CRB or service provider
will provide Tyro an assessment of whether the personal information disclosed by
Tyro matches personal information available through the DVS in relation to that
particular individual.
By agreeing to this Privacy Statement and Consent you, you agree to Tyro
disclosing your personal information to a CRB or other service provider for the
purpose of making a request for verification of your identification using the
verification methods set out above.
If you do not consent to your identification being verified using the above methods,
there are alternative verification options available. Please contact Tyro directly to
find out about these options.
For further information about the DVS please visit www.dvs.gov.au.
Consent and acknowledgement
By consenting to the collection, use and disclosure of personal and credit
information in accordance with this Privacy Statement & Consent and Tyro’s
Privacy Policy you acknowledge and agree that:
• Where you have provided information about another individual, you declare
that the individual has been made aware of the fact and the contents of this
Privacy Statement & Consent and the Privacy Policy.
• You release Tyro and each other entity referred to in this Privacy Statement
& Consent or the Privacy Policy (“Indemnified Party”) from liability for, and
indemnify Tyro and each Indemnified Party against, all claims and losses
arising out of the disclosures or exchange of personal or credit information in
accordance with this Privacy Statement & Consent or the Privacy Policy.
Page 8/9
Appendix 1: Additional Beneficial Owners (if applicable) A.F.C.2018.04.09

Complete if there are additional Beneficial Owners who control or own 25% or more of the Company

Additional Beneficial Owner 1 Additional Beneficial Owner 2

Full Name (as displayed on your Identification Documents) Full Name (as displayed on your Identification Documents)
Shubham Bassi
Residential Address Residential Address

Suburb State Postcode Suburb State Postcode

Country of Residence Date of Birth Country of Residence Date of Birth

D D MM Y Y Y Y D D MM Y Y Y Y
Please provide details of at least TWO of the following: Please provide details of at least TWO of the following:
Australian Driver Licence No. Expiry Date Australian Driver Licence No. Expiry Date

D D MM Y Y Y Y D D MM Y Y Y Y
Medicare Card No. Reference Expiry Date Medicare Card No. Reference Expiry Date

MM Y Y Y Y MM Y Y Y Y
Passport Number Expiry Date Passport Number Expiry Date

D D MM Y Y Y Y D D MM Y Y Y Y
Country Issued Country Issued
A certified copy of your A certified copy of your
identification document(s) may identification document(s) may
be required. be required.

Your Overseas Tax Obligations/Information Your Overseas Tax Obligations/Information

Complete this section only if:
• the Company is declared as a Passive NFE/NFFE
in section 2
and
• you are a Beneficial Owner who owns or
controls 25% or more of the Company
A. Are you a U.S. citizen?
B. Are you a tax resident of a country other than Australia?
No: please go to Question C.
Yes: please provide details for all jurisdictions in which
you are a resident for tax purposes.
Country of Tax Residence 1
Complete this section only if:
• the Company is declared as a Passive NFE/NFFE
in section 2
and
• you are a Beneficial Owner who owns or
controls 25% or more of the Company
No Yes A. Are you a U.S. citizen? No Yes
B. Are you a tax resident of a country other than Australia?
No: please go to Question C.
Yes: please provide details for all jurisdictions in which
you are a resident for tax purposes.
Country of Tax Residence 1

Taxpayer Identification Number (TIN) 1 Taxpayer Identification Number (TIN) 1

TIN unavailable: TIN unavailable:

Country of Tax Residence 2 Country of Tax Residence 2

Taxpayer Identification Number (TIN) 2 Taxpayer Identification Number (TIN) 2

TIN unavailable: TIN unavailable:

If any ‘TIN unavailable’ box is checked, please If any ‘TIN unavailable’ box is checked, please
provide an explanation. provide an explanation.

I certify the tax residence country/countries I certify the tax residence country/countries
C. C.
provided represents all countries in which I am provided represents all countries in which I am
considered a tax resident. considered a tax resident.

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