Application Form

Please complete the form below to apply for finance.

Personal Details

Applicant First Names
Applicant Surname
Marital Status
Number of Dependants
Spouse's First Names
Spouse's Surname
Date of Birth: Applicant Spouse
Driver's Licence No: Applicant Spouse

Contact Details

Current Address
Years At Address
Tenancy
Other (Detail)
Previous Address
Years At Address
Email Address
Phone Number: Home Work Mobile

Employment Details

Present Employer
Years
Address
Occupation
Previous Employer
Years
Spouse's Employer
Years
Address
Occupation

Reference Details

Parents Name/Nearest Relative
Address
Relationship
Account References 1
Account References 2
Bankers
Account No

Financial Details

(please tick assets which are jointly owned)

Assets		Joint
Home
Furnishings
Bank
Car
Investments
Other
Total

Liabilities
Mortgages
HP / Credit Accounts
Bank Overdraft
Other Creditors, Loans
Loans
Total
Net Worth

Income (monthly)
Average take home pay
Spouse's take home pay
Other Income
Total

Expenses (monthly)
Mortgages/Rent Payments
HP / Credit Accounts
Rates, Phone, Power, Insurance
Life Insurance / Building Society
Car and other expenses
Total

Information Statement/Authorisation Pursuant To The Privacy Act 1993 Please read this statement/authorisation notice in full.

Have you ever had or are there now any attachments or legal proceeding against you, or any action for payment default?

Yes No

If yes, please state details:

Terms and Conditions

I apply for a loan and certify that the particulars above and overleaf are true and correct and that I am over the age of 18 years and am not an undischarged bankrupt. Pursuant to the Privacy Act 1993 I authorise any finance company to contact any credit reporting agencies, credit providers, my employer(s), accountant(s), or any other source, to obtain, check and exchange (both now and in the future) such personal, financial and commercial information and references about me/us as is necessary for the purposes of considering this application, the protection and administration of any loan arising out of this application, and to assist in the enforcement of any agreement between me/us and any finance company. I agree that you may produce this authority to such parties for the purposes of collecting such information. Under the provisions of the Privacy Act 1993, you are entitled to have access and request correction to personal information held about you.

I agree that the information in connection with this finance application may be transmitted via facsimile and/or electronic mail, and I acknowledge that there may be some security risks associated with the transmission.

I have read and accept the terms and conditions within this informative statement/authorisation.

I Accept Terms And Conditions

Please ensure the details you have provided above are correct before submitting the application.

Verification

Enter Verification Code: In order for us to verify that you are a real person, please re-type these numbers and letters into the field provided below.