Title * MrMrsMissMsDrOther

First Name *

Middle Name(s) *

Last Name *

Preferred Name *

Any Aliases

Date of Birth (dd/mm/yyyy) *

Residential Address *

Postal Address (if different to residential address)

Home Number

Mobile Number *

Email Address *

Preferred method of contact * Telephone callSMSEmail

Next of Kin's full name *

Next of Kin's Relationship to you *

Next of Kin's Contact Number *

Your Occupation

Your Position

Your Accountant

Are you an Australian Citizen * YesNo

Are you a Permanent Resident * YesNo

If you are a Permanent Resident, please provide further details:

Do you have a Will? * YesNo

Do you have an Enduring Power of Attorney? * YesNo

Do you have an Advance Health Directive? * YesNo

If yes to any of the above, where are your documents located?

Do you have any other instructions, special requirements or requests?

How did you hear about us?

I understand and acknowledge the following:-

1. This in no way constitutes a formal retainer agreement;

2. I have not yet engaged Terra Firma Law to act for me;

3. Terra Firma Law will not act for me or take any action whatsoever on my behalf to protect my interest until such time as I enter into a formal retainer
agreement by signing a Disclosure Notice and Cost Agreement and pay funds upfront.

Yes, I agreeNo, I don't agree

Please note, for your initial consultation You will be required to produce:-

• Passport AND driver licence; or
• Passport OR driver licence AND birth certificate issued by the Registry of Births Deaths & Marriages AND Medicare Card.

Proof of any name change will also be required.