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First Name*
Last Name*
My referral application type is*
My location is
Legal name of entity entering the transaction with Latpay*

(i.e.) Company, Trust, Partnership, Individual
Trading As
ABN or CRN

20 characters
Address
Suburb or City
State
Zip or Postal Code
Country
- Check to add another address
Postal Address (if different to above)
Address line
Suburb
State
City
Postal Code or Zip Code
Country
Phone
Email

2. Who are the Individual(s) / Directors / Trustees / Partners involved in your business entities?
Authorised Representative 1
First Name
Surname
Date Of Birth
DD slash MM slash YYYY
Phone
Email
Authorised Representative 2
First Name
Surname
Date Of Birth
DD slash MM slash YYYY
Phone
Email

4. Governing Law and Jurisdiction
This Agreement shall be deemed to be made in the State of Queensland and shall in all respects be interpreted, construed and governed in accordance with the laws of Queensland, Australia, exclusive of the laws relating to conflict of laws.

IN WITNESS of which this Agreement has been duly executed by the parties. Signed for and on behalf of the Reseller , , of whose application is registered at listed address, , , .
This Agreement shall be deemed to be made in the State of Queensland and shall in all respects be interpreted, construed and governed in accordance with the laws of Queensland, Australia, exclusive of the laws relating to conflict of laws.

IN WITNESS of which this Agreement has been duly executed by the parties. Signed for and on behalf of the Reseller , Trading as listed, ABN number, of whose business is registered at listed address, , , .
*
- I have read the Terms and Conditions
Authorised Representative 1 Signature*
Print Name*
First Last
Title*
Date*
Authorised Representative 2 Signature
Print Name
First Last
Title
Date
Signed for and on behalf of LATPAY
DIRECTOR
Date
Phone
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