Application Form - Moneylender

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:
Years there:

Employed:	Yes	No (please specify benefit details)
Employed:	(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 pay per week Fortnight? $

Payment Protection Plan? click here for more info yes no

Type of security:

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

Car Details

Make:
Model:
Year:
Rego 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