JUST DOLLARS TRUST

LOANApplication

Applicant Information
Full Name:
Have you ever been known by any other name (alias/maiden name) YES/NO
Current or Previous Aliases:
Date of birth: / Telephone: / Mobile:
Current address:
OwnRent(Please circle) / Email:
Weekly payment or rent: / How long?
Previous address:
OwnedRented(Please circle) / How long?
Employment Information
Current employer:
Employer address: / How long?
Phone: / E-mail:
City: / Weeklyincome: / Position:
Are you employed: Full time/part time
Receiving an Income Support Benefit or ACC Payments? Specify benefit :
Weekly income:
Other sources of income:
List your last three employers or self-employment situations:
Employer: / Position: / When?:
Employer: / Position: / When?:
Employer: / Position: / When?:
FAMILY AND REFEREES
Name of a relative not residing with you:
Address: / Phone:
Relationship to you:
Name of a second relative not residing with you:
Address: / Phone:
Relationship to you:
Marital Status: (please circle)Single / De Facto / Married
Number of Dependent Children: / Ages of Dependent Children:
Please list two character and one work referee:
Character Reference Name:
Address: / Phone:
Character Reference Name:
Address: / Phone
Work Reference Name:
Address: / Phone:
STATISTICAL INFORMATION (This information does not affect your application)
Ethnic Identity: (please circle) PacificIsland / Maori / Pakeha.European / Other:
Gender: (please circle) Male / Female
Amount Applied for from Just Dollars: $ / Have you ever been declared bankrupt or had a No Asset Procedure? (please circle) YES / NO
ASSETS / LIABILITIES
What is the value? / Total amount owed
Home (Rateable Value) / $ / Mortgage / $
Car 1 / $ / Car 1 / $
Car 2 / $ / Car 2 / $
Household contents / $ / Bank overdraft / $
Bank Accounts / $ / Loans (specify) / $
Other Assets (specify) / $ / $
$ / Credit Card Limit:$ / Amount Owed $
$ / Other Liabilities (specify) / $
TOTAL / $ / $
total / $
INCOME / EXPENDITURE
Weekly/fortnightly/monthly (Please circle) / Weekly/fortnightly/monthly (Please circle)
Net Income (after tax)
Benefit/Wages/Other / $ / Rent/Mortgage/Board / $
Partner’s Net Income / $ / Rates / $
Family/Child/Accommodation
Support / $ / Insurance (circle applicable)
Car/House/Contents/Life/Medical / $
Other Income (specify) / $ / Telephone / $
Power / $
Loans (specify) / $
$
Hire Purchase (specify) / $
$
Vehicle Finance / $
Credit Card / $
Child Support / $
Food/Tobacco/Alcohol / $
Petrol/Fares / $
Children: education/pocket money/clothing/other / $
Entertainment / $
Other Commitments (specify) / $
TOTAL / $ / TOTAL / $
DECLARATIONS
I HEREBY CERTIFY THAT THE INFORMATION DECLARED IS TRUEAND CORRECT IN EVERY PARTICULAR.
I authorise any person or company to provide the officers and employees of Just Dollars Trust with such information as the Trust may require in response to its credit inquiries. I further authorise the officers and employees of Just Dollars Trust to furnish to any third party details of this application and any subsequent dealings that I may have with the Trust as a result of this application being actioned by the Trust.
Signature of applicant / Date

ID Confirmation: (you will be asked to present this id and sign this form at your lending interview)

Drivers Licence / Birth Certificate / Passport (please circle)
Number:Expiry:

I understand that Just Dollars Trust are asking 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 Just Dollars Trust information about me for that purpose.

Just Dollars 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 Veda Advantage credit reporting service, Veda Advantage may give the information to those customers.

Just Dollars Trust may use Veda Advantage’s credit reporting services in the future for purposes related to the provision of credit to me. This may include using Veda Advantage’s monitoring services to receive updates if any of the information held about me changes.

If I default in my payment obligations to Just Dollars Trust, information about that default may be given to Veda Advantage, and Veda Advantage may give information about my default to other Veda Advantage customers.

Signature of applicant / Date