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RETAILER INFORMATION RETAILER TO COMPLETE
Retailer Name Operator Name
Telephone Value of Goods $
Facsimile Deposit $
Email Term (Months)
DESCRIPTION OF GOODS Payment Frequency
Interest Free(Months)
Deferred Period(Months)
LOAN PURPOSE 
Loan Amount Required* $
Purpose of Loan
Vehicle
Personal
Debt Consolidation
Other
If other (please specify) 
Loan Security*
* Must be owned by applicant(s) or co-borrower.
Vehicle must be no older than 10 years.
Vehicle
House
Registration No. or Address of Security
MAIN BORROWER CO BORROWER / GUARANTOR ( )
Title* Title*
Marital Status* Marital Status*
First Name(s)* First Name(s)*
Surname* Surname*
Date of Birth*(DD/MM/YYYY) Date of Birth*(DD/MM/YYYY)
Residential Address* Residential Address*
Town / Suburb Town / Suburb
City City
Home phone* Home phone*
Work phone Work phone
Mobile phone Mobile phone
Email Email
Proof of Identity* Proof of Identity*
Drivers licence no.*
(for more info see below)		 Drivers licence no.*
(for more info see below)
Licence Version no.* License Version no.*
Vehicle Registration no. Vehicle Registration no.
Number of Dependants Number of Dependants
How long at above address? * Year(s) How long at above address? * Year(s)
Previous address
(if less than 3 years at above address)		 Previous address
(if less than 3 years at above address)
How long at previous address? Year(s) How long at previous address? Year(s)
BORROWER EMPLOYMENT CO BORROWER / GUARANTOR EMPLOYMENT
Employment Status* Employment Status*
Employers Name* Employers Name*
Occupation Occupation
How long at job? * How long at job? *
Salary / Wages*
(in the hand)		 $ Salary / Wages*
(in the hand)		 $
Estimated Living Expenses*
(before monthly commitments below)		 $ Estimated Living Expenses*
(before monthly commitments below)		 $
BORROWER EMPLOYMENT REFERENCE CO BORROWER / GUARANTOR EMPLOYMENT REFERENCE
Reference Name* Reference Name*
Reference Phone no.* Reference Phone no.*
FINANCIAL
Assets Liabilities Balance Monthly Payment Limit
Savings / Investments $ Bank overdraft $ $ $
Property $ Mortgages/Rent/Board $ $ $
Rental Property $ Personal Loan $ $ $
Motor Vehicle(s) no.
$
Hire Purchase $ $
Home Contents $ Hire Purchase 2 $ $
Other $ Credit Card $ $ $
Business Equity $ Credit Card 2 $ $ $
Total assets (A) $ Total liabilities (B) $
Equity (A) - (B) $
COMMENTS / CONTACT
Comments / Questions
What is the best time to contact you?
What type of contact do you prefer?  Email  Phone  Writing
BORROWER CO BORROWER / GUARANTOR
I have read and accept the Terms and Conditions and I agree with the Privacy Statement within this website. I / We warrant that the information provided in this application is true and correct.
I have read and accept the Terms and Conditions and I agree with the Privacy Statement within this website. I / We warrant that the information provided in this application is true and correct.
I Accept
I Accept
About our company
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