Pre-paid Funerals - Application Form to print out

Application to Form a Funeral Trust

Complete the form below, then print it out, sign it and post to:
Freepost 395, Pre-paid Funerals, PO Box 48 250, Silverstream 5142. Remember to include your cheque (your lump sum plus initial fee of $150) and to sign the form. Cheques should be made payable to "Guardian Trust".

Title Other title Your Surname
First Names

Contact Phone Number
Date of birth
email address

Address:

I apply to have a Funeral Trust created for me by Pre-paid Funerals (PpF) for the purpose of payment of my funeral expenses.

I understand that the terms and conditions of my Funeral Trust shall be as set out in the Funeral Trust Deed dated 9 November 2000, executed by the Guardian Trust Company Limited

I acknowledge my Funeral Trust will be settled and established upon acceptance of this application form and my payment.

I wish to make payment as follows:

Lump Sum (initial minimum $3000) of:

Plus fee of $150

My total payment please attach your cheque

Regular monthly payment PpF will send auto payment details

Until this future date:

Preferred funeral Director (if any):

Funeral Instructions (if any):

Verification of Identity
Where this application is being made by an authorised representative on behalf of the applicant, or where the applicant is not identified by personal cheque, then an agent of Pre-paid Funerals (PpF) must certify the applicant’s identification. A passport on its own is sufficient identification. Otherwise, two other forms of identification are required.

PpF Agent’s Declaration:
I have seen an original or certified copy of the applicant’s identification, as detailed below and have kept a copy of this identification for the PpF files. I have no reason to believe that the applicant is not who he or she claims to be.

ID document 1: Type: Number:

ID document 2: Type: Number:

Agent's signature

Date:

Privacy Act 1993
I understand the Privacy Act 1993 allows me to acces and correct any personal information held by Pre-paid Funerals, Congreve Financial Services Ltd, or Guardian Trust. I acknowledge that this personal information may be used to introduce me to other products/services offered by Congreve Financial Services Ltd.

Applicant's signature

Date:

Signature of PpF Acceptance

Date:

THANK-YOU. NOW PRINT THIS OUT, SIGN, OBTAIN AGENT SIGNATURE IF NECESSARY, THEN POST WITH PAYMENT TO
Freepost 395, Pre-paid Funerals, PO Box 48 250, Silverstream 5142.

Please be aware that this form may make two pages when printed out.