GoEscrow Forms

A. Personal Details

First Name

Last Name

Date Of Birth

Email Address

Mobile Phone

Search Australian address (optional)

Search for an Australian address or enter it manually below.

Unit Number (optional)

Street Number

Street Name

Suburb

State

Post Code

Country

B. Identification

The Mobile-ID SMS flow is not available while this form is configured for Email Only submission. Please complete one identification option below.

Identification type

Select one identification type. Only the selected document fields will be shown.

Drivers Licence

Issuing State

Licence Number

Card Number

Expiry Date

Passport

First Name

Middle Name (If it appears on passport)

Last Name

Document / Passport Number

Country

Place of Birth (optional)

Date of Issue

Date of Expiry

Medicare Card

Card Colour

Green Blue Yellow

IRN

Name (exactly) as on card

Medicare Card Number

Expiry Date (MM/YYYY)

The IRN is the number next to the name on the front of the Medicare card. View example Medicare card

Centrelink Card

Centrelink Card Type

HCC Health Care Card PCC Pensioner Concession Card SHC Senior Health Care Card

Customer Reference Number (CRN)

Name on Centrelink card

Expiry Date

ImmiCard

ImmiCard Type

AMS Australian Migration Status EIS Evidence Of Immigration Status PRE Permanent Residence Evidence RDI Residence Determination

ImmiCard No (Card Number)

Expiry Date

Given Name(s) (exactly as on card)

Surname (exactly as on card)

C. Personal Bank Details

You may provide your personal bank account now for future refunds or Payee/Seller transactions.

Account Name

Bank/Institution Name

BSB

Account Number

PayID (optional)

SWIFT (optional)

Bank account name should closely match the individual's name. GoEscrow may remit a $0.01 transfer and request a transaction reference code as confirmation. SWIFT codes are required for international bank accounts. Further details may be requested for international settlements.

D. Source of Funds and Wealth

Do you expect to participate in GoEscrow transactions above $25,000?

Select Yes if you expect to participate in GoEscrow transactions above $25,000. This optional embedded section lets you provide high-level Source of Funds and Wealth details early.

Yes No

For transactions above $25,000.00, GoEscrow may request information regarding your financial situation. You may optionally submit this information now.

Expected GoEscrow use

What types of transactions do you expect to use GoEscrow for?

Used Goods Registered Vehicle Resale Machinery/equipment Tradie Style Services Renovation/building Projects Major Construction Professional services Business sale Marine/aviation Domain/digital asset Intellectual Property Transfer High-value goods Executed Contract Facility Warranty and Guarantee Leins Property Sale Deposits Property Liens Replacement of Lawyer Trust Functions Other

Please specify other

Typical transaction value range

Source of Funds

Where are the funds you expect to use with GoEscrow generally expected to come from?

Source of Funds means how you obtained the money you expect to use in GoEscrow transactions — for example wages, savings, business income, asset sale proceeds, inheritance or finance. It is about how the money was obtained, not simply the bank account it is transferred from.

Salary / wages Personal savings Business income Sale of property Sale of vehicle, goods, equipment or other asset Sale of shares or investments Loan or finance Gift from family or another person Inheritance Superannuation / pension Insurance payout Legal settlement Digital asset / cryptocurrency sale Overseas transfer Cash savings or cash deposit Other

Please specify other

Will any third party provide funds?

Select Yes if third parties other than the GoEscrow account holder or named transaction parties may make direct payments into the escrow transaction accounts on your behalf.

What is the third party’s relationship to you or the entity?

Please briefly describe the relationship

Are any funds expected to come from outside Australia?

Select Yes or Unsure if any money may come from outside Australia. This helps GoEscrow understand whether escrow payments may have an overseas source.

Please list potential countries

List any countries where funds may originate from, be held, or be transferred through before reaching GoEscrow. Approximate countries are acceptable if not yet final. Do not enter bank account numbers or sensitive login details.

Are any funds expected to come from cash deposits or digital assets / cryptocurrency?

Select Yes or Unsure if the funds may originate from cash deposits, digital assets or cryptocurrency. This helps describe the type of funds that may be used with GoEscrow.

Source of Wealth

How have you mainly accumulated your overall wealth or financial position?

Source of Wealth means how you built your overall wealth or financial position over time — for example employment or business income, property, investments, inheritance or asset sales. It is broader than Source of Funds and is not limited to the money used in a GoEscrow transaction.

Employment income Business ownership Property ownership or property sales Investment income or investment growth Inheritance or family wealth Superannuation Professional practice income Farming / agricultural income Other

Please specify other

Approximate annual income band

Other declarations

Are you acting for another person or entity?

Select Yes if you are completing this information for, or acting on instructions from, another person or entity.

Any bankruptcy, insolvency, freezing order or similar restriction?

Select Yes or Unsure if there is any bankruptcy, insolvency, freezing order, court order or similar restriction that may affect funds or authority to transact.

Are you a wholesale client or sophisticated investor?

In Australia, some people may be treated as wholesale clients or sophisticated investors if they hold a current certificate from a qualified accountant confirming they meet certain income or asset thresholds.

Anything unusual about the source of funds or wealth GoEscrow should know?

Use this optional field for anything GoEscrow should know about the source of funds or wealth that may not be obvious from the answers above.

E. Authority and Execution

Section A of this form has matched the email address, mobile phone number or ABN to an existing GoEscrow account. A new application is not required. Please use the GoEscrow apps or contact customer service if this is incorrect.

I authorise GoEscrow Pty Ltd ACN 650 709 354 to create an account in my name. I am the person in the identification data in section B and I consent to my information being checked with the document issuer or official records holder via third party systems for the purpose of confirming my identity. I have read, understood and agree to the Terms Of Use Agreement and have read and understood the Product Disclosure Statement and Financial Services Guide.

First Name

Last Name

I confirm I am the applicant I confirm the information supplied is true, accurate and complete. Digital signature acknowledgement.