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Last Name *
First Name *
Middle Name
Date of Birth *
Home Phone *
Mobile Number
Work Phone *
Email address *
Street *
Suburb
City *
Status Rent Own Home Board
How long have you lived at the current address years *
Street
City
Gross Annual Income $0 - $20000 $20001 - $30000 $30001 - $40000 $40001 - $50000 Over $50000
Occupation *
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Name *
Relationship to you *
Phone Number(Land-line preferred) *
ID Type - Drivers Licence Passport Amex Diners Visa Bankcard Mastercard *
ID Number *
I / We authorise you to collect, use and disclose information about me / us for any purpose related to the contract (including any Credit Reporter with whom we have dealings, and including the Insurance Company who issued the the policy I / We may have purchased), and I / We authorise any other person to disclose this information to you for that purpose.
This information is collected and required to enable Smiths City (Southern) Limited to consider this application for credit. You have the right of access to your personal information held by Smiths City (Southern) Limited and shall be entitled to correction of such information. (Smiths City (Southern) Limited does not sell, rent, share, or otherwise give your personal information to third parties for marketing purposes.)
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