eCosway Store Operator Application Form

NZ Ver 5, Updated: Dec 20127. REFEREES ( REFEREES PROVIDED SHOULD NOT BE RELATIVE OR PRESENT EMPLOYER)FULL NAMEDETAILS REFEREE 1 REFEREE 2ID NOeCOSWAY MEMBERSHIP NOADDRESSCONTACT NORELATIONSHIP8. DECLARATION / CONSENTI HEREBY SOLEMNLY DECLARE THAT THE INFORMATION DISCLOSED IN THIS APPLICATION IS TRUE, COMPLETEAND CORRECT TO THE BEST OF MY KNOWLEDGE AND UNDERSTANDING. I UNDERSTAND AND ACCEPT THATANY FALSE STATEMENT OR WITHHOLDING OF ANY RELEVANT INFORMATION MAY PROVIDE GROUNDS FORTHE WITHDRAWAL OF ANY OFFER OF APPOINTMENT OR FOR ITS IMMEDIATE CANCELLATION IF THEAPPOINTMENT HAS BEEN ACCEPTED.I understand that by signing this application, consent is given to Cosway New Zealand Ltd toDisclose to a credit reporting agency personal information about me including: identity particulars.Obtain to a credit reporting agency a report containing personal credit information about me and, a report containinginformation about my commercial activities or commercial credit worthiness, to enable Cosway New Zealand Ltd to assessthis application for the position of company store operator. I further consent to and acknowledge that Cosway New ZealandLtd may at it’s discretion obtain second and/ or subsequent credit reports to assess this application.Give and obtain from any credit provider(s) that may be named in this application or in a report held by a credit reportingagency information regarding this application.Note: A security deposit of $3,000 will be required from all free store operators. This deposit will need to be paid upfront beforethe commencement of the store.________________________________SIGNATURE OF APPLICANT_________________________DATE