Client Verification Form

Full Name
New Zealand Resident
Full Name
New Zealand Resident
Referrer Name
Please confirm that you have read the public available disclosure statement for Insurance & Mortgage Network and personal disclosure for Jai Bothra
The role of the referrer is to collect information, not to give advice. Has the referrer followed this?
Do you allow the referrer to forward your information to Insurance & Mortgage Network?
Do you give Insurance & Mortgage Network all necessary consent and authority to act as your agent?
The purpose of lending is for:
I declare that the information provided to the best of my knowledge are accurate
I am happy for Insurance & Mortgage Network to obtain non obligatory pre approval / refix-rates on my behalf