Splash Internet Pty Ltd
Appointment of an Authorised Representative


How to appoint an Authorised Representative:

When you appoint an Authorised Representative you are giving the person you appoint the 
authority to deal with us on your behalf as your agent. This means that the Authorised 
Representative has the power to act and access information as if they were you. This 
includes making complaints, changing account details or terminating a contract. You can of 
course specify limitations of your Authorised Representative’s rights. 
Please note that only account holders can appoint an Authorised Representative. If you wish 
to appoint more than one Authorised Representative, please complete one Authorised 
Representative Form for each person you wish to appoint. You can appoint up to three 
Authorised Representatives.
For security reasons we require you to submit the completed Authorised Representative 
Form to us as a signed original and witnessed by one of the following persons below:


• A Justice of the Peace;
• An Accountant who is a member of the Australian Institute of Chartered Accountants, 
CPA Australia or the National Institute of Accountants with 2 or more years of 
continuous membership;
• A Solicitor or Barrister;
• A Police Officer;
• An agent in charge of, or a permanent employee (with 2 or more years of continuous 
service) of an Australia Post outlet;
• An officer with, or authorised representative of, a holder of an Australian Financial 
Services Licence, having 2 or more continuous years of service with one or more 
licensees;
• A Dentist;
• A Pharmacist;
• A Medical Practitioner;
• A Chiropractor or a Physiotherapist


Please contact us on (02) 6100 4600 if this proves too difficult or inconvenient for you, and 
we will work with you to find an alternative way of appointing an Authorised Representative.

 

Appointment of Authorised Representative Form

Your details:

Account holder’s full name (note: you must be the account holder to appoint an Authorised 

Representative):

___________________________________________________________________

“I wish to appoint the following person as my Authorised Representative”:
Your Authorised Representative’s details
Authorised Representative’s full name:

____________________________________________________________________
Authorised Representative’s telephone number:

____________________________________________________________________
Authorised Representative’s email address (if applicable):

____________________________________________________________________
Authorised Representative’s physical address:

____________________________________________________________________
Limitations of the Authorised Representative’s rights (Specify anything that your Authorised 
Representative should NOT be allowed to do on your behalf. If left blank, the Authorised 
Representative has the power to act as if they were you.):

___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
__________________________________________________________________________________________

Appointment declaration:

“I, ___________________________________________________, authorise Splash Internet Pty Ltd to 
deal with the above person as my Authorised Representative. I acknowledge that I am
responsible for all acts of my Authorised Representative within the authority as described in 
this Appointment. Splash Internet Pty Ltd may assume that it is dealing with the Authorised 
Representative if they identify themselves as such when contacted at any of the contact 
numbers/addresses above. This appointment continues until I revoke it in writing.”

Signature:

Place and date:

____________________________________________________________________
Account holder’s signature:

____________________________________________________________________
Witness’s declaration and signature: 

“I confirm that the person signing above (account holder) has produced evidence of their 
identity.”
Place and date:

____________________________________________________________________
Witness’s signature:

____________________________________________________________________
Witness’s full name:

____________________________________________________________________
Witness’s capacity (JP, police officer etc.) and address:

____________________________________________________________________
____________________________________________________________________
____________________________________________________________________