DATE:…./…../…..

3033 Great North Road P.O. Box 15364

New Lynn New Lynn 0640
Auckland 0600 CONFIDENTIAL LOAN APPLICATION Telephone 09 826 0222

LOAN AMOUNT: ..................................................SECURITY: CHATTELS / VEHICLE VEHICLE REGO: ..........................

PURPOSE OF LOAN: ............................................ HOW DID YOU HEAR ABOUT US: .............................................................

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MR / MRS / MISS / MS CLIENT NO: .................... Single De facto Married Widow
Surname: ....................................................................... First Names: .............................................. D.O.B: .........................
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MR / MRS / MISS / MS CLIENT NO: ...................... Single De facto Married Widow
Surname: ....................................................................... First Names: .............................................. D.O.B: .........................
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RENTING / BOARDING / HOME OWNER
Address: ............................................................................................................................................ Since: ..........................
Mobile:........................................................................... Mobile: ..........................................................................................
Home Phone: ................................................................. Email: ............................................................................................
Landlord / Home Owner: .....................................................................................................................................................
Previous Address: ......................................................... .................................................................. Since: ..........................

OCCUPATION: ................................................................ EMPLOYER: ............................................... Since: ..........................

Address: ......................................................................... Work Contact: ...............................................................................

OCCUPATION: ................................................................ EMPLOYER: ............................................... Since: ..........................

Address: ......................................................................... Work Contact: ...............................................................................

Other Income:.......................................................................................................................................................................

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NUMBER OF DEPENDANTS: ............ BENEFICIARY: YES / NO WHICH BENEFIT: ........................................................

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INCOME FREQUENCY REPAYMENT METHOD PAYMENT DAY
WEEKLY / FORTNIGHTLY / MONTHLY DD / AP / WAGES / OTHER: Mon / Tue / Wed / Thu / Fri

REFERENCES (Family or friends not living with you)

Name: ...................................................................................... Phone Number: ..................................................................
Address: ................................................................................... Relationship: .......................................................................

Name: ...................................................................................... Phone Number: ..................................................................

Address: ................................................................................... Relationship: .......................................................................

Name: ...................................................................................... Phone Number: ..................................................................

Address: ................................................................................... Relationship: .......................................................................
 PRIVACY WAIVER
I, ...........................................................................................................................................................................................
Do hereby declare that the given information is true and correct and consent to the collection, use and disclosure of
my personal information by Aotea Finance Limited and its associated companies, its employees and agents (“Aotea”)
for the following purposes:

 Granting of credit to me and any other associated activity;

 Verifying any personal information provided by me with third parties, including Government agencies. Where
I have provided driver licence information, this information may be disclosed to a credit reporting agency and
verified with the NZ Transport Authority database;
 Carrying our credit checks on me with a credit reporting agency;
 Obtaining information about me from a credit reporting agency relating to the provision of credit to me;
 Debt recovery including appointing an agent to collect any outstanding debts and listing defaults with a credit
reporting agency;
 Checking the Ministry of Justice files database for any overdue fines I may have. This will require disclosure of
my personal information to the Ministry of Justice. This check may be carried out by a credit reporting agency,
which will require the search results being disclosed to the credit reporting agency.

I authorise any person to provide Aotea with any personal information that Aotea may require for any of these
purposes. In addition, I specifically authorise and request the following to provide to Aotea my personal information
(including names, address, telephone number, income, assets and liabilities):

1. Trade and/or personal creditors

2. Any finance company
3. Any trading bank
4. Any Government agency including Work and Income New Zealand (WINZ), Inland Revenue Department,
Ministry of Justice, Housing New Zealand, Immigration Department, NZ Transport Authority (Motor Vehicle
Register) and Ministry of Business, Innovation and Employment (PPSR)

I understand that any credit reporting agency to whom you may disclose my personal information may hold that
information on their credit reporting database and use that information for the purpose of providing credit reporting
services or for any other lawful purpose and may disclose that information to their subscribers for the purpose of credit
checking or debt collection or for any other lawful purpose.

I understand that if I have provided driver licence information that the provision of this information was voluntary
(unless Aotea advises otherwise). I understand that my personal information may be collected, used and disclosed by
Aotea without my knowledge and without consultation with me.

Aotea may also use its irrevocable power of attorney to obtain information about me and that for the purpose of
obtaining information I have appointed Aotea as my agent.

SIGNATURE OF CUSTOMERS AND WITNESS

Signed: ........................................................................ Witness:

Signed: ........................................................................ Witness:

Date: ........................................................................... Date: