Custom Application

Fields marked with an * are required

Are you an existing client?*

Yes

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Franchisee

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Franchisee Email

Personal Details

First Name*

Middle Name

Last Name*

Date of Birth *

Day*

Month*

Year*

Hidden

Date of Birth

Gender

Male

Female

Email*

Phone*

Hidden

Phone - International Format for Twilio SMS

Current Address

House number and Street Name*

Suburb*

State*

Postcode*

Length at this address *

Years*

Months

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Length at this address

Previous Address

House number and Street Name

Suburb

State

Postcode

Household

Living Situation*

Dependents - Children*

Relationship Status*

Num adults sharing costs*

Additional Comments

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How did you hear about us?

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Marketing opt-in

Please tick this box if you DO NOT wish to receive our specials

Your comments/notes

Almost there...

Fields marked with an * are required

Driver's Licence Number*

Put NA if not applicable

Are you on Centrelink?*

Yes

CRN*

Which Benefit?*

Do you have rentals with other companies coming out of Centrepay? If so, what are they?*

Are you employed?*

Yes

Employer Name*

Employer Phone*

Employer Address*

Position*

Annual Wage*

I am renting this product because*

I am entering my income and expenses figures as:*

Income

Centrelink*

Wages*

Other*

Hidden

Total Income

Expenses

Mortgage/Rent

Loan Repayments

Utilities

Phone & Internet Expenses

Transportation

Food

Other Expenses

Hidden

Total Expenses

Disposable Amount

Is your situation likely to change in the foreseeable future?*

Yes

Landlord Contact Details

Landlord Name*

Landlord Phone*

Landlord Address

Reference 1 (not living with applicant)

First Name*

Last Name*

Phone*

House number and Street Name

Suburb

State*

Postcode

What's your relationship?*

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Reference 2 (not living with applicant)

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First Name

Hidden

Last Name

Hidden

Phone

Hidden

House number and Street Name

Hidden

Suburb

Hidden

State

Hidden

Postcode

Hidden

What's your relationship?

Privacy Statement

Direct Appliance Rentals Privacy Statement:
Direct Appliance Rentals Pty Ltd (ACN 098 305 714) trading as Direct Appliance Rentals and its authorised representatives and franchisees (collectively Direct Appliance Rentals) is committed to ensuring the confidentiality and security of the personal information of its clients, and is also committed to complying with the Privacy Act 1988 (Cth) (which includes the Australian Privacy Principles) and the Anti Money Laundering and Counter Finance Terrorism Act 2006.

The Direct Appliance Rentals Privacy Policy details our handling of personal information.

This application form will be processed by Direct Appliance Rentals and your eligibility for our credit product will be assessed based on the information you disclosed to us.

By submitting this application form, you consent to the collection, use and disclosure of your credit related information (as defined in our Privacy Policy) by Direct Appliance Rentals and or any of its authorised representatives and franchisees.

If you do not provide some or all of the information requested on our application form, we may not be able to accept your application or otherwise provide you with our services.

Direct Appliance Rentals may use information received from you to send marketing material to you from time to time unless you elect not to receive it. Direct Appliance Rentals will not provide your information to any third party other than in accordance with the Direct Appliance Rentals Privacy Policy.

By checking this box I indicate:*

By checking this box I indicate:

I have read and understand the Privacy Policy
I can afford to make the fortnightly repayments
I have read the Credit Guide and Information Statement

Phone

This field is for validation purposes and should be left unchanged.

Custom Application

Personal Details

Current Address

Previous Address

Household

Additional Comments

Almost there...

Income

Expenses

Landlord Contact Details

Reference 1 (not living with applicant)

Reference 2 (not living with applicant)

Privacy Statement

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