PUMA RETAIL PARTNER APPLICATION
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1 PUMA RETAIL PARTNER APPLICATION Document Prepared by Puma Energy
2 PERSONAL INFORMATION Surname: First Name: Address: State: Country: Suburb/Town: Postcode: Years in current address: Home Phone: Work Phone: Mobile: address: Date of Birth: Australian Citizen: Yes / No If no, are you a permanent resident? Yes / No EDUCATION Highest level of education: Institution: learning/education: Printed Copies are UNCONTROLLED Page 2 of 11
3 WORK EXPERIENCE Present: Current Role: Year Started: Job Description: Past: Previous Role: Year Started: Job Description: Reason for Leaving: Previous Role: Year Started: Job Description: Reason for Leaving: Previous Role: Year Started: Job Description: Reason for Leaving: Printed Copies are UNCONTROLLED Page 3 of 11
4 ADDITIONAL BUSINESS Are you currently involved in any other business? Yes / No If yes, what? Have you been a director of a company in the past 5 years? Yes / No If yes, what was the name of the company? What is their ABN? Have any of the companies you have been a director of been declared bankrupt or charged with fraudulent conduct? Yes / No If yes, please provide details: PHYSICAL HEALTH Do you have any physical health condition(s) which may affect you operating a Retail Site? Yes / No If yes, what? Printed Copies are UNCONTROLLED Page 4 of 11
5 OTHER INTERESTS Are you involved in any local community groups? Yes / No If yes, what? Why? Any other interests? APPLICANT DETAILS How did you discover this Retail Partner / Service Station opportunity? Do you have any specific Retail Service Station locations in mind? Yes / No If yes, please specify: Printed Copies are UNCONTROLLED Page 5 of 11
6 GENERAL As a Retail Partner, what do you expect from Puma Energy? Have you ever been convicted of a criminal offence? Yes / No If yes, please specify: Have you ever been charged of a criminal offence? Yes / No If yes, please specify: Do you authorise Puma Energy to request a Police Clearance? Yes / No Do you understand that you must make your own financial and legal enquiries regarding this business? Yes / No Do you understand that you must comply with Puma Energy s standards and guidelines? Yes / No Do you understand that there is no guarantee of future earnings? Yes / No Printed Copies are UNCONTROLLED Page 6 of 11
7 BANK DETAILS Who do you bank with? Branch: Contact: Phone Number: ASSETS AND LIABILITIES ASSETS DESCRIPTION Market Value of Home Market Value of Property (commercial and residential) Market Value of Vehicles Value of Shares Investment Savings Accounts Cheque Accounts Equity in Business Superannuation Total Asset Value VALUE / WORTH Printed Copies are UNCONTROLLED Page 7 of 11
8 LIABILITIES DESCRIPTION Home Mortgage Investment Loans Vehicle Loans Personal Loans Credit Card Balance Overdraft Total Liabilities VALUE / WORTH NET ASSETS Total Assets - Total Liabilities = Net Assets $ - $ = $ FUNDING How do you intend to fund your Retail Service Station investment? Explain: Printed Copies are UNCONTROLLED Page 8 of 11
9 ADDITIONAL INFORMATION Please provide anything else to support your application here: REFEREE 1: Name: Address: Occupation: Years Known: REFEREE 2: Name: Address: Occupation: Years Known: REFEREE 3: Name: Address: Occupation: Years Known: Printed Copies are UNCONTROLLED Page 9 of 11
10 STATEMENT The information provided is an accurate record of my personal and financial situation. I authorise Puma Energy to contact any appropriate third parties or credit agencies to verify the accuracy of the information submitted herein and to retain such information for their records. If requested by Puma Energy, I agree to supply information from my professional advisors (i.e. banker, broker, accountant or solicitor) verifying the above statements. I understand that Puma Energy is relying upon all the above information as a material factor in considering my application to become a Puma Energy Retail Partner. Name of Applicant: Signature of Applicant: Date: Printed Copies are UNCONTROLLED Page 10 of 11
11 COME AND TALK TO US Ph W E retailpartner.au@pumaenergy.com BRISBANE (HEAD OFFICE) Level 1, North Tower, Green Square, 515 St Pauls Terrace, Fortitude Valley QLD 4006 PO Box 95 Fortitude Valley QLD 4006 DARWIN 5 Wishart Road Berrimah NT 0828 GLADSTONE 69 Hanson Road Gladstone QLD 4680 PERTH Level 4, 59 Albany Highway Victoria Park WA 6100 Printed Copies are UNCONTROLLED Page 11 of 11
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