Please complete this questionnaire and e-mail it back to ps@avantus.co.

za

Personal

Full Name JAN HEYNS DU PREEZ

Nickname

Marital Status Single / Widow(ed) / Married

Married how ICP / ANC / Accrual Yes - No

Children – Name and age RENE HEYNS DU PREEZ - 14

ANDREAS HEYNS DU PREEZ - 5

Occupation / Job title SENIOR PROCESS ENGINEER

Qualification (s) B.TECH CHEMICAL ENGINEERING

Contact details

Home Tel 076 2812213

Cell number 076 9939267

Home address 3 CONSTITUTION ROAD, HAARLEM, 6467

Postal address BOX 25, AVONTUUR, 6490

Other

Smoking status Smoker / Non smoker

Wedding Anniversary 08/07/1994

Last Will and Testament In place / not in place

Who is executor ABSA

Do you have a trust Yes / No

Tax office GEORGE

Tax number 0451187025

Medical aid company DISCOVERY

Assurance Policies -
N/A
Companies
For peace of mind and an up to date schedule (inclusive group and personal) the following
authorization document (for information purposes only) must be signed and returned to me. If
married, spouse to sign as well. Attached find my disclosure document as required by law.

Thanking you, Pieter Stassen

 I, ___________________________________________ and spouse __________________________________________ [Full names],

with ID’s ___________________________________________ and ___________________________________________________

in my/our personal capacity or, where applicable, in a representative capacity for and on behalf of
__________________________
_________________________________________________________________ [State if not applicable],acknowledge the following:

CLIENT AUTHORISATION

sound and proper financial advice can only be provided with full disclosure of relevant Information relating to appropriate
personal, including private, information for the purposes of determining and advising on my/our financial situation and
financial product experience and objectives, in the process of acquiring, servicing or maintaining any financial products,
including but not limited to any information relating to or interest in any long-term insurance, unit trust or any other
financial products or services, with any long-term insurer, unit trust manager or other financial institution; and

my/our interests shall be best served if that Information is made available to authorised financial service providers with a
legitimate interest in receiving such information for those purposes.

I/we accordingly confirm, for the purposes of providing the said sound and proper financial advice to me/us, that full
permission and authority is granted to:

PIETER STASSEN / M GRIFFIOEN [PIETER JACOBUS STASSEN T/A AVANTUS - LICENCE NUMBER 13597],

to obtain any and all such Information via The Financial Services Exchange (Pty) Ltd, trading as Astute, or any other
financial institution providing such information.

I/we herewith give consent for the long-term insurer, unit trust manager or other financial institution possessing such
Information to release such Information to the said Authorised User direct or via Astute, and I/we confirm that such
Authorised User shall be acting on my/our behalf or in my/our interest and I/we waive any right to privacy.

I/we further acknowledge that this consent to obtain information on my behalf will remain effective until cancelled by
me/us in writing.

Thus done and signed at _________________________________ on this __________ day of ______________________, 200___.

________________________________________ ___________________________________________
Signature of Client Signature of Spouse

Fax number: (044) 873 6477 E-mail: ps@avantus.co.za

Pho Tel number: (044) 873 4050 Cell: 082 563 4563

Authorisation Note
 BROKER DISCLOSURE UNDER THE POLICYHOLDER PROTECTION RULES

Full names, title and designation of Broker: PIETER JACOBUS STASSEN, MR

Postal Address: PO BOX 3241, GEORGE-IND, 6536
Physical Address: 96 MERRIMAN STREET, GEORGE
Telephone No: (044) 873 4050 Fax No: (044) 873 6477 / 0866161819
Cell No: 082 563 4563 E-mail: ps@avantus.co.za Web Address: www.avantus.co.za

1 Legal status of Pieter Stassen.

Pieter Stassen is an independent broker trading as Avantus. Other independent brokers are Hendrik Griffioen and Michael Meiring.

I am an authorized financial services provider, licensed to render financial services. A copy of the license, which
contains details of
the financial services I am authorized to provide, as well as any exemptions, is available for inspection on request.
FSB number: 13597
2 Contractural relationships of Pieter Stassen and Avantus with insurers:
OLD MUTUAL GROUP ALTRISK SHAREMAX
LIBERTY GROUP PIC
SANLAM GROUP
DISCOVERY HEALTH & WEALTH SANTAM
MOMENTUM GROUP MUTUAL & FEDERAL
3 Experience of Pieter Stassen:
I have experience in providing advice on the following topics:
RETIREMENT PLANNING TAX PLANNING
INVESTMENT PLANNING INSURANCE
ESTATE PLANNING HEALTHCARE PLANNING
BUSINESS ASSURANCE CORPORATE BUSINESS
I have been offering financial planning advice for more than 10 years (since 1984).
4 Qualifications: As per Financial Services Board requirements.
5 Professional bodies to which I belong:
Masthead (Financial Advisors Association). Compliance with the FAIS Act is monitored by Masthead Distribution
Services (Pty) Ltd, a
compliance practice approved by the Financial Services board. The contact telephone number is 021 686 3588. I am
a proud member
of the Masthead Financial Advisors Association, which provides me with services such as a compliance, practice
management and
technology support by virtue of my membership.

This support helps me to provide you with a more professional service. The compliance service ensures that my business
remains fully compliant with FAIS legislative requirements and therefore that you as customer receive sound financial
advice. Through the practice management support, [my staff and] I am/are able to run a more professional business and
therefore are able to provide you with an improved service and enhanced support.

I may from time to time receive non-cash incentives from product suppliers or indirect consideration from other persons. I
will provide specific details should you request further information.
6 Pieter Stassen is insured by the Professional Indemnity Insurance of Glenrand.
7 COMPLAINTS POLICY
In the event that you are dissatisfied with any aspect of my service, you should address your complaint in writing to me at
the above address. A copy of my Complaints Policy is available on request.
8 Accreditation of Pieter Stassen:
I am authorized to sell insurance products as stated in my letters of authority.
1 I do not hold directly or indirectly more than 10% of any insurers shares.
2 I did receive more than 30% of my last years commission and remuneration from the following insurer(s): LIBERTY and
OLD MUTUAL
1 I do not deal with any undeclared funds.
2 I am paid for my services: By receiving commission from the companies concerned.

____________________________________ ____________________
FINANCIAL ADVISOR (PIETER STASSEN) DATE