The Independent AdvisorCertification Panel

Independent by design
Agricultural Finance

TheIndependent
Advisor

Certification Panel
Application Form

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The Independent Advisor — Certification Panel: Application Form

This form is used to apply for independence certification. The panel verifies your licence or accreditation directly with the relevant regulator, checks your insurance and conduct history, and reviews any conflicts of interest you disclose. Applications are usually reviewed within 10 business days.

Applicant & Business Details

Legal / business name *

ABN / ACN *

Contact person (full name) *

Phone *

Email *

Category applying under *

Applying under more than one category? Please submit a separate form for each.

Years operating in this category *

Licence / Credential

Licence, registration, or accreditation number *

Issuing body (e.g. ASIC, TPB, LPBWA, Fertcare, DEMIRS) *

Licence expiry / renewal date *

I consent to the panel verifying this directly with the issuing body or regulator. See our Privacy Policy for how this information is used. *

Do you have any current banning, disqualification, suspension, or enforcement action against you? *

Yes No

If yes, please provide full details

Only complete this if you answered Yes above.

Insurance

Insurer name *

Policy type *

Coverage limit ($) *

Policy expiry date *

Certificate of currency *Upload PDF, JPG, or PNG…

PDF, JPG, or PNG accepted.

Conduct History (last 5 years)

Any disciplinary finding, upheld complaint, or investigation by a regulator or professional body in the last 5 years? *

Yes No

If yes, please provide full details

Only complete this if you answered Yes above.

Reference 1 — name *

Business *

Phone *

Reference 2 — name *

Business *

Phone *

Independence & Conflict of Interest Declaration

A 'Yes' answer in this section does not automatically fail the application. An untruthful 'No', discovered later, is treated as a breach of trust.

Do you receive commission, referral fee, rebate, or profit-share connected to products or services you recommend? *

Yes No

If yes, provide full details: who pays it, on what basis, which products/services it relates to

Only complete this if you answered Yes above.

Do you, or a business partner, hold an ownership interest, directorship, or referral arrangement with a business in another advisor category? *

Yes No

If yes, name the related business, its category, and the nature of the arrangement

Only complete this if you answered Yes above.

Is each relationship declared above disclosed to your clients as standard practice, or only on request? *

Do you, or your licensee, use the words 'independent', 'impartial', or 'unbiased' in your own marketing? (Applies to AFSL/ACL-licensed applicants only.) *

Yes No Not applicable

I confirm I meet the conditions of section 923A of the Corporations Act (no commissions, no volume-based payments, no product-issuer ownership or control).

Only tick this if you answered Yes to the question above.

Remuneration & Commission/Referral Disclosure Statement (if applicable)Upload PDF, JPG, or PNG… (optional)

PDF, JPG, or PNG accepted. Optional.

Declaration & Consent

I declare the information in this application is true and correct to the best of my knowledge. *

I consent to the panel conducting independent verification, including register searches and referee contact. See our Privacy Policy for how this information is used. *

I understand my listing may be suspended pending investigation of any complaint, and that I must notify the panel within 14 days of any change to my licensing status, insurance, or the matters declared above. *

Signature or typed full name *

Position / title *

Date *

Fields marked * are required.