Galaxy Coins and Cash For Gold Australia

1. Personal Information

Full Legal Name (as per ID)

Previous Names (if any)

Gender Select gender Male Female Other Prefer not to say

Please specify gender

Date of Birth

Nationality

Australian Residency Status Select status Citizen Permanent Resident Temporary Resident Other

Please specify residency status

2. Contact Information

Primary Phone Number

Alternative Phone Number

Email Address

Preferred Contact Method Select contact method Phone Email SMS

3. Identification Documents

Primary ID Document Type Select ID type Australian Passport Australian Driver's License Photo Card Foreign Passport

ID Number

Expiry Date

State of Issue (if applicable) Select state New South Wales Victoria Queensland Western Australia South Australia Tasmania Australian Capital Territory Northern Territory

Secondary ID Document (if applicable)

May be requested for additional verification

4. Residential Address

Street Address

Suburb

State Select state New South Wales Victoria Queensland Western Australia South Australia Tasmania Australian Capital Territory Northern Territory

Postcode

Is your mailing address different from residential address?

Yes No

Mailing Address

Street Address

Suburb

State Select state New South Wales Victoria Queensland Western Australia South Australia Tasmania Australian Capital Territory Northern Territory

Postcode

5. Employment and Income

Employment Status Select employment status Employed Self Employed Retired Student Unemployed Other

Please specify other employment status

Occupation/Business Type

Employer Name (if applicable)

Annual Income Range Select income range $0 - $30,000 $30,001 - $60,000 $60,001 - $100,000 $100,001 - $150,000 $150,001+ Prefer not to say

6. Purpose of Purchase

Type of Purchase Select purchase type Investment Collection Gift Other

Please specify purpose

Additional Details (Optional)

7. Source of Funds

Primary Source of Funds Select source of funds Savings from Employment Investment Returns Inheritance Business Income Sale of Assets Other

Please specify source of funds

Evidence of Funds (Optional)

May be requested for verification purposes

8. Bank Account Details

This information is required for any potential refunds or transactions. The account must be in your name.

Account Holder Name

Bank Name

BSB Number

Account Number

9. Risk Assessment

Criminal History Declaration

As required by AML/CTF legislation, please declare if you have any criminal convictions or pending charges.

Have you ever been convicted of a crime or have any pending criminal charges?

Yes No

Please provide details

Politically Exposed Person (PEP) Declaration

A PEP is an individual who is or has been entrusted with prominent public functions, their family members, or close associates.

Are you a PEP or associated with a PEP?

Yes No

Please provide details

Scam Awareness Declaration

Please confirm your awareness of potential scams and that you are making this purchase of your own free will.

I confirm that:

I am making this purchase voluntarily and have not been pressured or coerced by any third party I understand the risks associated with precious metals investment and am not responding to unsolicited investment advice I am not purchasing on behalf of someone else or being directed by a third party

10. Declarations

Please confirm the following:

I declare that all information provided in this form is true and correct I understand that providing false or misleading information may constitute an offense I agree to notify Galaxy Coins and Cash For Gold Australia of any changes to the information provided I consent to the collection and verification of my personal information as required by AML/CTF legislation

Submit KYC Form