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Who are you?

Borrower Guarantor

Title:

Mr Mrs Ms Miss Other

Date of Birth:

  dd/mm/yyyy

First Names:


(If known by any other name i.e.; Maori or Maiden names please provide details)

Surname:

E-mail:

If the security offered is jointly owned by two people (borrower or guarantor), the following panel must be completed by the second borrower/guarantor.

Who are you?

2nd Borrower 2nd Guarantor

Title:

Mr Mrs Ms Miss Other

Date of Birth:

dd/mm/yyyy

First Names:


(If known by any other name i.e.; Maori or Maiden names please provide details)

Surname:

House:

Owned Rented Board Other

Phone (day):

Phone (evening):

Phone (mobile):

Address:

Town/City:

Years There:

Previous Address

Address:

Town/City:

Years There:

Employed:

Yes 

No (please specify benefit details)

(please complete employers details) 

Benefit

Employed by:

 Occupation:

 Phone:

Years Employed There:

Local relative not living with you

Title:

Mr Mrs Ms Miss Other

First Names:

Surname:

Address:

Town/City:

Phone:


Amount of Loan Sought: $

 

How much can you afford to repay per week/ fortnight? $

 

Loan Repayment Insurance required? (click here for more info) yes no

 

Type of security offered:

Car
Home
Property
Other (excludes house chattels)  
Reason for loan:

 

Car Details

Make:

Model:

Year:

 

Reg Number:

Ownership:

Self
Joint
               (both names)

Amount owing on vehicle:

$
Name of Finance Lender:

Do you have a guarantor/s?

Yes No

Name of Guarantor/s:

 
 

 Please indicate you have read and accept the Privacy Waiver 

I AGREE

Borrower

2nd Borrower

 

Guarantor

2nd Guarantor