I understand that this page grants permission for my financial mentor to speak to other organisations about my finances *

Yes

Name *

First Name

Last Name

Name also known as

(optional)

First Name

Last Name

Date of birth *

MM

DD

YYYY

Today's date *

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YYYY

Agreement end date *

This agreement expires on:

Open ended agreement

Agreement expires on a set date (enter below)

Date agreement expires

If you wish the privacy waiver to end on an agreed date enter it below

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DD

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Permission to provide information “Other organisations” = any bank, business, creditor, organisation, department, service or person involved in my financial affairs. *

Yes, I authorise other organisations to give any personal information about my financial affairs to my financial mentor and/or the service as requested.

*

Yes, I authorise my financial mentor and/or the budgeting service to discuss my financial affairs with other organisations so the financial mentor can provide me with appropriate budgeting advice.

*

Yes, I intend that this authorisation satisfies the requirements of the Privacy Act 1993.