Internet/Telephone Banking* Application Form

Client / Log-on Number

I am applying for (please tick the appropriate box/es)

Internet banking Telephone banking

Customer Information (Please complete if your details have changed)

Title

Surname *

First Names *

Date of Birth *

IRD Number

RW Tax Rate or Non Resident

Please choose closest region

Home address *

City *

Postcode *

Mailing address (if different from home address)

City

Postcode

Telephone Home *

Telephone Work

Mobile

Fax

Email *

Occupation

Internet / Telephone Banking

Accounts that I would like to access via Internet / Telephone Banking

1.
Account number

Suffix
2.
Account number

Suffix
3.
Account number

Suffix
4.
Account number

Suffix

Southern Cross is a division of Heartland Building Society (“Society”).

Privacy Act Consent and Account Conditions

Pursuant to the PRIVACY ACT 1993 Southern Cross advises that:

a) This form collects personal information about you;
b) The information is being collected to enable you to apply for and use the Society's telephone and internet banking services in connection with one or more bank accounts with the Society that you hold and to obtain the use of other Society products and services;
c) The intended recipients of the information are the Society and its agencies. Your information may also be provided to:
- i) research firms, for the purposes of providing generic research about the Society's customers (to be undertaken on a "no-names" basis); and
- ii) direct marketing firms engaged by the Society, for the purpose of various marketing initiatives that may be undertaken by the Society;
d) The information is being collected by and held at Southern Cross, PO Box 554, Auckland;
e) Failure to provide this information or provision of incorrect information may result in your application for telephone and internet banking services being declined or your application for other Society products and services being declined;
f) You have rights of access to, and correction of, personal information supplied to and held by the Society.

Important: This application is made subject to the Society's Terms and Conditions for Southern Cross accounts

Authorisation:

I agree that my name, address and phone numbers may be used by the Society to advise me of other products or services and by research firms engaged by the Society to carry out customer research and surveys, and direct marketing firms engaged by the Society.
I confirm my personal information provided to the Society and recorded above to be true and correct as at today's date.
Where I am applying for Internet Banking, I have read and agree to the Society's Terms and Conditions. for Southern Cross accounts
Where I am applying for Telephone Banking, I have read and agree to the Society's Terms and Conditions. for Southern Cross accounts

Once you have completed the online application process, you will still need to sign your application at some stage. One of our branch staff will be in touch to go through this application with you and answer any questions you may have. Simply hit “Apply Now” .

As an alternative, you can also select to print this application, so you can sign it and send it into one of our local branches or Agencies for processing. To do this please hit “Print Your Results” below.

*Heartland Building Society is not a registered bank. Obtaining bank registration is subject to the satisfaction of Reserve Bank of New Zealand requirements.

Southern Cross Building Society