Ipswich Intermediary Panel Application Please print all details clearly and return the form to Mortgage Sales Team at [email protected], by fax to 01473 278600 or by post to Building Society, PO Box 547, Ipswich IP3 9WZ

Intermediary Title: Mr / Mrs / Ms / Miss / Other

Details Name:

Business Name / Name under which FCA registration granted

(For limited companies only) Company Registration Number:

Business Address

Postcode Correspondence Address (if different from business) We will require signed confirmation on the registered company letter head Postcode

Tel. No. Mobile Number

Email

FCA Is the firm: Directly authorised Directly authorised FCA Number Registration Appointed representative Appointed representative FCA Number

Principal Company Name (AR's only)

If you will be submitting an application via a mortgage club, please list all clubs here:

Have you at Been subject to disciplinary action by the firm, FCA or any supervisory body? Yes No any time: Been convicted of a criminal offence? Yes No Had a CCJ registered against you? Yes No Entered into an arrangement with creditors? Yes No Been the subject of a receiving order? Yes No Been the director of a company subject to winding up procedures? Yes No

If you have answered 'Yes' to any of the above, please provide full details on a separate sheet.

Professional Please provide a copy of your current PI certificate with this application Indemnity Insurer: Policy number: Insurance Expiry date: Amount of cover: We kindly request that the up to date PI Policy Schedule is sent to us upon expiration of the current policy provided

Consumer Firms have to be authorised by the FCA to carry out consumer credit activities, please confirm which Credit Activities permission level you currently hold:

Interim permission Full permission activities

Please confirm the renewal date of your permission:

Bank Procuration fees are paid by BACS. To ensure prompt payment can be made following completion of your Details case, please provide current details as applicable on signed letter headed paper with this application

Please note that it is your responsibility to ensure that you inform us of any changes to these details promptly.

Treating Please confirm you apply the principles of Treating Customers Fairly and Good Conduct of Business at all times Customers and in your dealings with customers Yes No Fairly

PLEASE READ THE TERMS OF BUSINESS AND DECLARATION OVERLEAF BEFORE SIGNING THIS FORM

MOR61 (03/15) IPSWICH BUILDING SOCIETY TERMS OF BUSINESS FOR INTERMEDIARIES By joining our panel you agree to accept our general terms of business for intermediaries, as follows. The Society reserves the right to remove you from its intermediary panel if you do not adhere to the general terms.

TERMS OF BUSINESS It is your responsibility to ensure that: • you always have your customer’s authority to act on their behalf, and their permission to pass information to the Society • your customer is fully aware, that when the Society searches their credit file to assess either an AIP or Application, a record of that search will be left (i.e. it will leave a hard footprint on the customers records) • you have all the appropriate, current authorisations from the Financial Conduct Authority (FCA) to submit applications • you will hold the relevant permissions with the FCA to conduct Consumer Credit Activities and Professional Indemnity Insurance cover at all times • you only submit business for your own customers and you will not process or submit any business through us on behalf of another adviser • the Society can carry out ongoing reviews when required to assess your ongoing panel membership

INTERMEDIARY DECLARATION • I confirm that in accordance with current Anti Money Laundering Regulations, I will have undertaken appropriate ‘Know Your Customer’ checks including the verification of identity and recording the details of all mortgage applicants before passing applications to Ipswich Building Society • I confirm that any information Ipswich Building Society holds about me and how I use their website may be used for monitoring and management information purposes. This may be shared with the management team within my own organisation • I indemnify Ipswich Building Society in respect of any liability, losses, damages or costs it may incur arising from a breach of my warranties and/or obligations, imposed by these terms of business, or by reason of any misrepresentation or negligent, or fraudulent act or default by me

I agree to Ipswich Building Society making checks as they deem necessary prior to appointing me to their intermediary panel, and at any future time, including credit checks, business searches and ongoing business reviews.

Signature Date

Authorised by the Prudential Regulation Authority and regulated by the Prudential Regulation Authority and the Financial Conduct Authority. Registered on the Financial Services Register, number 104875.

HEAD OFFICE - PO Box 547 Ipswich IP3 9WZ Telephone 0330 123 1073 Fax (01473) 278600 Email [email protected] Website www.ibs.co.uk