Please use the form below to provide us with some basic details about you. All details will only be used in the strictest confidence & will not passed onto any 3rd party. You are under no obligation & will not incur any cost by applying for surgery financing. Once we have received your application, a member from our Customer Service team will be in contact with you.

Required *
 
 
Applicants Information Collection form - Private & Confidential

Please complete the application below and someone will contact you.
  1 PERSONAL DETAILS
 
Title Surname*
Full given names*
Home phone Work phone Mobile phone*
Email address*
Loan Amount($) Practise/Doctor*
Date of birth  Sex Marital status Driving license number
Male Female
 
  2 INCOME DETAILS
 
Net monthly Job description* Occupation Name of employer How long
years month
 
  3 ASSETS
 
  Owner Market value
Personal home Self       Joint  
Investment property Self       Joint
Bank Balance Self       Joint
 
  4 OTHER ASSETS
 
  Owner Company Policy number Market value
Superannuation Self       Joint
Motor vehicle Self       Joint  
Home content Self       Joint
Other Self       Joint
 
  5 LIABILITIES
 
  Owner Company Credit limit
Credit card 1 Self       Joint
Credit card 2 Self       Joint
Credit card 3 Self       Joint
 
  Owner Mortgagor Balance owing
Home loan Self       Joint
Investment property Self       Joint
Personal loan Self       Joint
Car loan Self       Joint
Other Self       Joint
 
  6 LIVING ARRANGEMENT
 
Current living Current address if renting, real estate name, suburb
weekly rent and time at address

Previous living 		Previous address if living for less than
3 years at current address		 if renting, real estate name, suburb
weekly rent and time at address
Reference/Next
of Kin Name		 Reference/Next of Kin Address Reference/Next of Kin Contact Number