Third party authority to access information form

Retail Collections
GPO Box E237
PERTH WA 6841
Phone: 1300 787 144
Facsimile: 1300 769 041
THIRD PARTY AUTHORITY TO ACCESS INFORMATION FORM
Email: [email protected]
CUSTOMER DETAILS
Customer 1
Full Name
Address:
Customer 2
Full Name
Address:
Date of Birth
Date of Birth
ACCOUNT DETAILS
Option 1: Information on individual accounts (check box and complete table)
Account Type
Account Number

OR
Option 2: All Current Accounts (check box)
An account number is required to link all current accounts (please enter here)

AUTHORITY DETAILS
Option 1: Friend or family member to have access to information & act on your behalf
(Check box and complete table)
Full Name
Date of Birth
Residential Address
Contact Number(s)
Password

*Please check box if you only want your friend/family member to be contacted 
OR
Option 2: Agent or Legal Representative to have access to information & act on your behalf
(Check box and complete table)
Agency/Law Firm Name
Name of Representative
Address
Contact Number(s)
Agent’s ABN / Registration
Number

I / we, in accordance with section 18N of the Privacy Act 1988, authorise the above individual or agency/law firm to act as my/our
agent in relation to or concerning my/our accounts as listed above to:

Seek and exchange personal information about me and my accounts from Bankwest (or their representative)

Negotiate with Bankwest (or their representative) and enter into arrangements that are binding on me.
I / we authorise and request the disclosure to the third party listed above, on their request, any such information relating to or
concerning my/our accounts listed above.
I / we understand that:

I, or my authorised representative, may revoke this authority at any time by written or verbal notification

Standard account notifications may continue to be sent to my mailing address

If an agreement is made, my written consent may be required

Bankwest may contact me directly if unable to contact my authorised representative within a reasonable period of
time

Bankwest may contact me directly where they believe my authorised representative may not be acting in my best
interests (in line with Section 2:9 of the Debt Collection Guidelines)
Signed: ______________________________________________________ Dated: _________________
Signed: ______________________________________________________ Dated: _________________
In completing this form, you consent to Bankwest collecting information so that we, and your authorised representative, can help you with your account(s), financial
difficulty or other issues. If the information is not complete or accurate this may affect the ability of Bankwest to assist you.
Bankwest’s Privacy Policy tells you what we do with your personal information and how to access that information. It also includes our policy on the handling of credit reports
and other credit-related information. A copy of Bankwest’s Privacy Policy is available on our website, by calling our Contact Centre on 13 17 19 or from your local Store.
TPA2
Bankwest, a division of Commonwealth Bank of Australia, ABN 48 123 123 124 AFSL / Australian credit licence 234945