FIELDLINE FINANCE
APPLICATION
Please fill in the following details
and once completed email to
[email protected]
FINANCE APPLICATION - CONSUMER
PURCHASE DETAILS
GUARANTOR/SECOND APPLICANT
Surname/s (Mr/Mrs/Miss/Ms) __________________________________________
Surname/s (Mr/Mrs/Miss/Ms) __________________________________________
First and Middle Name/s ______________________________________________
First and Middle Name/s ______________________________________________
Address ____________________________________________________________
Address ____________________________________________________________
____________________________________________________________________
____________________________________________________________________
Postal Address (if different) ____________________________________________
Postal Address (if different) ____________________________________________
____________________________________________________________________
____________________________________________________________________
Telephone (home) ________________________(work) _____________________
Telephone (home) ________________________(work) __ ___________________
(mobile)_______________________
(mobile) _______________________
NZ Resident
NZ Resident
Y
N
Date of Birth _____________________
Y
N
Date of Birth _____________________
Country of Birth ______________________________________________________
Country of Birth ______________________________________________________
Citizenship (1) _______________________________________________________
Citizenship (1) _______________________________________________________
Citizenship (2) _______________________________________________________
Citizenship (2) _______________________________________________________
Drivers Licence Number _______________________ Version # (5b) _________
Drivers Licence Number _______________________ Version # (5b) _________
Residence
Own
Rent
Board
How Long ______ yrs
Residence
Own
Rent
Board
How Long ______ yrs
Previous Residence
Own
Rent
Board
How Long ______ yrs
Previous Residence
Own
Rent
Board
How Long ______ yrs
Address ____________________________________________________________
Address ____________________________________________________________
Marital Status _________________
Marital Status _________________
Dependants: Number _____ Ages_____
Dependants: Number _____ Ages_____
Occupation _________________________________________________________
Occupation _________________________________________________________
Full Time
Full Time
Part Time
Self Employed
Unemployed
Part Time
Self Employed
Unemployed
Employer & Address __________________________________________________
Employer & Address __________________________________________________
__________________________ Phone______________ How Long _______yrs
__________________________ Phone______________ How Long _______yrs
Previous Occupation _________________________________________________
Previous Occupation _________________________________________________
Full Time
Full Time
Part Time
Self Employed
Unemployed
Part Time
Self Employed
Unemployed
Employer & Address __________________________________________________
Employer & Address __________________________________________________
_________________________ Phone______________
_________________________ Phone______________
How Long _______yrs
How Long _______yrs
Nearest Relative (not living with you) ____________________________________
Nearest Relative (not living with you) ____________________________________
Address ____________________________________________________________
Address ____________________________________________________________
____________________________________________________________________
____________________________________________________________________
Telephone ____________________
Telephone ____________________
Relationship _________________________
PURCHASE FINANCIAL DETAILS
ASSETS
LIABILITIES
INCOME
Balance
Relationship _________________________
Monthly Payment
Mortgage/Rent$__________ $__________
Property$__________
Take Home Pay
Loans
$__________$__________
Vehicles $__________ Wk/Ft/Mth
Credit Cards $__________
$__________
Furniture & Effects $__________
Spouse/Partner
Other $__________
$__________
Other $__________ Wk/Ft/Mth
$__________
$__________
DECLARATION
Authorisation for collection, use and disclosure of information
I/we understand and authorise that
The information received from me/us will be securely held by the Dealer and/or Finance Company
I/we may access and correct this information under the Privacy Act 1993
The information may be used by the Finance Company and/or the Dealer to
• consider my/our application for facilities, products or services or any future applications for facilities
products or services
• administer, manage and monitor any facilities, products or services provided to me/us
• obtain information about my driver license from Driver Check, a secure internet site set up by the
NZ Transport Agency, such as licence classes and endorsements held, and licence conditions and
licence status
• conduct market research, data processing and statistical analysis and
• unless I/we disagree, provide me/us with information about other facilities products or services
including selected third party products or services
The Finance Company and/or the Dealer may disclose information about me/us to its rotated companies
(as defined by the Companies Act 1993) agents or contractors for the above purposes
The Finance Company and /or the Dealer may disclose information about me/us to credit reference
agencies for the purpose of obtaining a credit report on me/us. Those credit reference agencies may
retain that information and provide to their customers who use their credit reporting services.
If I/we default in any obligations to the Finance Company and/or the Dealer then information about me/us
may be disclosed to credit reference or debt recovery agencies and retained by them. Those agencies
may provide that information to their customers who use their credit reporting services.
The Finance Company and the Dealer may each obtain information and make such enquirers about me/
us as each of them considers is warranted from any source including from its related companies (as
defined by the Companies Act 1993) and credit reference agencies for the above purpose.
TOTAL$__________
Personal Property Securities Act 1999 Verification Statement Waiver
The customer waives/does not waive [Delete one. If no deletion, to be read as “waives”] the need for the
Finance Company to forward it a copy of any verification statement in respect of any financing statement
or financing change statement registered under the Personal Property Securities Act 1999 (“PPSA”) by
the Finance Company in connection with any agreement.
SIGNED BY PURCHASER/S GUARANTOR/S
I/we warrent that the information provided above is true and correct and I/we acknowledge it will be relied
upon by the Finance Company to determine whether or not to accept my/our application for finance.
Full Name _____________________________________________________________
Date _________________________________________________________________
Full Name _____________________________________________________________
Date _________________________________________________________________
I/we have read and agree to the declaration, and confirm I/we are the named person/s above.