Marital Status
single married de facto divorced widowed
Name & Date of Birth
Title
First Name
Middle Name
Last Name
Date of Birth
Preferred Name
Current Residential Address & Contact Details
Unit Street No.
Street or Rural Delivery
Suburb/Town Home ph
Email Address Mobile ph
Postal Address (if different from above)
PO Box or Private Bag
Suburb/Town
Current Residential Status
owner renting boarding living with family
Time at current address (years and months)
Time at previous address (years and months)
Previous NZ Residential Address
If renting or boarding, please give name and number of agent or landlord
Name phone
Vehicle make and model Vehicle reg
Are you a permanent resident in NZ? yes no
If you weren't born in NZ, how long have you lived in this country? (years and months)
YOUR INCOME
Annual income (before tax)
Bank Accounts Held: cheque savings credit card
YOUR EMPLOYMENT DETAILS Employer's details or Accountant's if self employed.
Name
Address
Work Phone
Occupation
Income Source
self employed public company government employee
health/education welfare/benefit retirement savings/superannuation
private person spouse's income student allowance/loan
private company other? (explain)
Time at current employment (years and months)
Time at previous employment (years and months)
This information will be used by the Lender for the following purposes; assessing your credit worthiness, administering, financing and enforcing your purchase agreement, offering insurance to you, maintaining credit records with Lender and Retailer, marketing goods and services provided by the Retailer or Finance Company.
You authorise the Lender/Retailer to:
I apply for credit from Capricorn Limited ("The Lender") and certify that the information on this application is true and correct and that I am not an undisclosed bankrupt. I confirm that I have read and understood the Privacy Consent.
I accept the above conditions I DO NOT accept the above conditions
