Authority to Obtain Confidential Information (Form A)

Fields marked with an * are required



I/We give authority to Collins House Private Wealth (Collins House), a Corporate Authorised Representative of Collins House Private Wealth Pty Ltd (AFSL No. 449146), and its Financial Advisors, Consultants, and staff, namely Mr Dominic Alafaci, Mr Sam Campisi, Ms Kate Nicol, Mr Lloyd Masocha, Ms Moira Bentley, Ms Claire Jin, Ms Yi Li, Mrs Neda Kuzmic, Ms Heidi Motte and Mr James Campisi, authority to obtain any confidential information they may require regarding the above.

The authority is to remain valid until revoked.

If you have any queries, please contact Collins House as below:

PHONE (03) 9629 6922
EMAIL mail@collinshouse.com

POST
PO Box 24175
Melbourne VIC 3001

OFFICE
Level 13, 90 Collins Street
MELBOURNE VIC 3000

Confirmation of supplied details