Application Form


Amount to Borrow: * $

APPLICANT 1
Title:
Given Name:
Surname:
Date Of Birth: (dd/mm/yy)
Age of dependent children:
Drivers License Number:
Version Number (found at 5B): Expiry Date: (dd/mm/yy)

Residential Details
Flat/House No.: Street:
Suburb: City: Postcode:
Length of time at current address: Years: Months:
Residential Status:
Home Phone: Mobile Phone:
Email Address: *

Employment Details
Occupation:
Employer:
Employers Address:
Work Phone:
Length of Time
Years: Months:

Financial Details
Weekly Income:
(after tax/child support)		 $
Credit Card Limit: $ Credit Card Balance: $
What I/we own Value Weekly Outgoings Value
House: $ Food & Petrol: $
Motorbike: $ Mortgage & Rent: $
Home Contents: $ Credit Cards: $
Vehicles No.: $ Hire Purchase 1: $
Boat/Caravan: $ Hire Purchase 2: $
Shares/Superan:
Bonus Bonds		 $ Loans guaranteed:
for others		 $

Details:


APPLICANT 2
Title:
Given Name:
Surname:
Date Of Birth: (dd/mm/yy)
Age of dependent children:
Drivers License Number:
Version Number (found at 5b): Expiry Date: (dd/mm/yy)

Residential Details
Flat/House No.: Street:
Suburb: City: Postcode:
Length of time at current address: Years: Months:
Residential Status:
Home Phone: Mobile Phone:
Email Address:

Employment Details
Occupation:
Employer:
Employers Address:
Work Phone:
Length of Time Previous
Years: Months: Years: Months:

Financial Details
Weekly Income:
(after tax/child support)		 $
Credit Card Limit: $ Credit Card Balance: $
Weekly Outgoings Value
Food & Petrol: $
Mortgage & Rent: $
Credit Cards: $
Hire Purchase 1: $
Hire Purchase 2: $
Loans Guaranteed:
for others		 $

Motor vehicle
available for security.		 Make: Model: Year: Reg. No.:
Real Estate
offered as security		 House Value: Mortgage Owing:
Purpose of Loan:
Credit References:
Next of Kin: Address: Phone:

PRIVACY CLAUSE

PRIVACY, CONSENT TO USE AND DISCLOSURE OF INFORMATION

I acknowledge that the information I have provided will be used by Martyn & Perriam for the following purposes:
- assessing my credit worthiness - administering, financing,insuring and enforcing this and any other account with Martyn & Perriam - maintaining the integrity, accuracy and effectiveness of its credit records and those of credit reference agencies.

I authorise Martyn & Perriam to collect, retain and use this information for the purposes listed above. I authorise Martyn & Perriam to collect, retain and use such other information as it may require for the purposes listed above from any other source including credit reference agencies and I authorize each on them to disclose that information to Martyn & Perriam. I authorise Martyn & Perriam to disclose the information it holds to other persons but only where disclosure is:
required or permitted by law. to any employee or agent Martyn & Perriam or its successors or assigns. to credit reference agencies. to Martyn & Perriam legal or other professional advisors.
in any other circumstances authorised by me.
I understand that I have the right of access to and correction of my personal information held by Martyn & Perriam. I declare that I have never entered into any arrangement or composition with my creditors nor committed any act of bankruptcy nor suffered any warrant to be levied against me and that I am not a discharged bankrupt. I understand that failure to supply the information to Martyn & Perriam, or supply false information may prejudice or preclude the favorable determination of my application for credit. I understand that any information supplied in support of this application will remain the property of Martyn & Perriam ACKNOWLEDGEMENT I understand that any sales voucher or request for credit, signed by me/us, shall have no effect unless and until Martyn & Perriam has approved this application. Where there are two applicants Martyn & Perriam may communicate acceptance of this application to either of us.