RETAILER INFORMATION
Retailer Name
*
Telephone
Facsimile
EMail
DESCRIPTION OF GOODS
*
Operator Name
*
:
Note: Press TAB to go to next field.
Value of Goods
*
:
Deposit
*
:
Term (Months)
*
:
6
12
18
24
36
Payment Frequency
*
:
Please Select
Weekly
Fortnightly
Monthly
Interest Free
:
Months
Deferred period
:
Months
PURCHASER INFORMATION
Given Name
*
:
Please Select
Mr.
Mrs.
Ms.
Middle Names
:
Surname
*
:
Proof of Identity
*
:
Please Select
Drivers License
Passport No.
Credit Card No.
ID No
*
:
Date of Birth
*
:
(
e.g
.
31
/
01
/
1980
)
Vehicle Registration No
:
CUSTOMER INFORMATION
Customer to complete
PHYSICAL ADDRESS
Street Address
*
:
Suburb
*
:
Town / City
*
:
Post code
:
Since how long at above address
*
:
Please Select
< 12 months
1 year
2 years
3 years
> 3 years
PREVIOUS ADDRESS (if less than 3 years at above address)
Full Address
:
For how long at above address
:
Please Select
< 12 months
1 year
2 years
3 years
> 3 years
POSTAL ADDRESS (if different than physical address)
Street Address
:
Suburb
:
Town / City
:
Post code
:
CONTACT DATAILS
Home Telephone No.
*
:
Please Select
09
07
06
04
03
Is the number above listed in your name?
*
:
Yes
No
Mobile Phone No.
:
Email
:
Please fax photo identification of either your driver's licence or passport to 09-478 1456
EMPLOYMENT
Employment Status
*
:
Please Select
Employed
Self-employed
Student
Beneficiery
Retired
Occupation
:
Work Phone No.
:
Please Select
09
07
06
04
03
Employers Name
:
Since how long?
:
Please Select
< 12 months
1 year
2 years
3 years
> 3 years
Position
:
Previous Employers Name
:
How long at Job?
:
Please Select
< 12 months
1 year
2 years
3 years
> 3 years
Previous Employers Phone No.
:
Please Select
09
07
06
04
03
NEXT OF KIN ADDRESS (not living with you)
Next of Kin Name
*
:
Next of Kin Address
*
:
Next of Kin Phone No.
*
:
Please Select
09
07
06
04
03
GENERAL
Marital Status
*
:
Please Select
Married
Single
De Facto
Name of the Partner
:
Number of Dependants
:
Please Select
0
1
2
3
4+
Personal Weekly Income (Before Tax - Applicant Only)
*
:
Please Select
$200-$299
$400-$599
$600-$799
$800-$1199
$800-$1199
$800-$1199
Other
If Other (Specify)
:
Do you have content insurance?
:
Please Select
Yes
No
Insurance Company Name
:
Home Owner
*
:
Please Select
Yes
No
Value of Home (Approx)
:
Balance of Mortgage(Approx)
:
CREDIT REFERENCE- LOANS OUTSTANDING : ($ Approximations Only)
Name of Company :
Original Balance:
Balance Owing:
Monthly Payments:
PRIVACY ACT
Credit Reporting Privacy Code 2004
I hereby authorise any person or company to provide you or Gilrose Finance Co Limited with such information as you may require in response to your enquiries associated with this application. I also further authorise you to furnish to any third party or parties details of this application and any subsequent dealings that I may have with you as a result of this application being actioned by you. I hereby declare that the information provided is true and correct and that I am not an undischarged bankrupt. I agree that the financier may nominate the insurer at its discretion. I understand that Gilrose Finance Company Ltd have asked me for personal information about me so as to use Veda Advantage's credit reporting service to credit check me. I understand that:
Veda Advantage will give you information about me for that purpose. You will give my personal information to Veda Advantage, and that Veda Advantage will hold that information on their systems and use it to provide their credit reporting service. When other Veda Advantage customers use the Veda Advantage credit reporting service, Veda Advantage may give the information to those customers. If I default in my payment obligations to you, information about that default may be given to Veda Advantage, and Veda Advantage may give information about my default to other Veda Advantage customers.
ACCEPTED
Applicant First Name
*
:
Applicant Surname
*
:
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Gilrose
. All Rights Reserved.