Application For Credit

Please fill out the form fields below & click the submit button when finished.
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* denotes compulsory field.

Alternatively you can download the form, print it out and fax it to 372 9049.

Click here to download application form (PDF format).

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Personal Details

Purpose of Loan (Full Details)
*

Title
Please Select Mr Mrs Ms Miss Other *

Surname
*

First Names
*

Date of Birth
*

Maiden or Other Surnames
*

Marital Status
Please Select Single Divorced Married Other

Home Phone
*

Email Address
*

Work Phone
*

Accommodation
Please Select Own house Rent Board *

No. of Dependants
Please Select 0 1 2 3 4 5 *

Home Address
*

How long at Home address?
*

Previous Address:
*

How long at Previous address?
Please Select 0 1 2 3 4 5 6+ *

Employment details

Current Employer Name
*

Address

Phone
*

Occupation
*

Length of Service
*

Type of employment
Please Select Full Time Part Time Seasonal Self-Employed Retired Other

Previous Employer Name

Previous Employer Occupation

Previous Employer Length of Service

Contacts

Next of Kin Name (at a different address)
*

Relationship to you
Please Select Please select Father Mother Son Daughter Brother Sister Cousin Uncle Aunt Other *

Address
*

Phone
*

Other relative or close friend (living on Waiheke)
*

Relationship to you
Please Select Please select Friend Father Mother Son Daughter Brother Sister Cousin Uncle Aunt Other *

Address
*

Phone
*

Spouse

Full name of Spouse / De-Facto Partner

Date of Birth

Occupation

Employer

Work Phone

Credit History

Name of Finance Company/Lender number 1
*

Account Number
*

Type of Credit
Please Select Mortgage Bank Loan Hire Purchase *

Date Commenced / Period
*

Remaining Balance
*

Name of Finance Company/Lender number 2

Account Number

Type of Credit
Please Select Mortgage Bank Loan Hire Purchase

Date Commenced / Period

Remaining Balance

Credit Card details

Credit Card Type
Please Select Visa Master Card American Express Bank Card Diners Club Other None *

Issuing Bank
Please Select ANZ ASB BNZ Kiwibank TSB Westpac N/A

Year of Issue
Please Select 2001 2002 2003 2004 2005 2006 N/A *

Total Limit

Remaining Balance
*

Assets

Make/Model of Motor Vehicle if owned
*

Registration Number
*

Year
Please Select before 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Financed By

Insurance

Do you have private insurance that will cover the goods being purchased? If so, please enter:
Insurance Company

Do you have any form of insurance covering loss of earnings and/or ability to earn? If so, please enter:
Insurance Company

Income And Expenditure

Normal Net Wages (After Tax, Weekly)
*

Spouses Net Wages (After Tax, Weekly)
*

Regular Household Expenses Weekly)
Please Select 250-300 300-350 350-450 450-600 600+ *

Liabilities

Mortgage/Rent/Board (Weekly)
*

Motor Vehicle Payments (Weekly)
*

Loan/Hire Purchase (Weekly)
*

Credit Card Repayments (Weekly)
*

This Loan(Weekly)
*

Total Liability Payments (Weekly)
*

Please include additional Comments here

Consent to terms and use and disclosure information

I warrant that the particulars set out herein are true and correct. I declare that I am over the age of eighteen (18) years, further, I declare that I have not been adjudged bankrupt, nor suffered any warrant to be levied against me, and that I am not an undisclosed bankrupt. I accept that this form and the information contained herein shall remain the property of Te Huruhi Finance. I understand that I have the right of access to and correction of my personal information held by Te Huruhi Finance. I also understand that while outstanding monies are owed to Te Huruhi Finance, even if not overdue, it is my responsibility to inform Te Huruhi Finance of any relevant change in my personal details, including a change of address. I acknowledge that the information I have provided will be used by Te Huruhi Finance for the purposes of assessing my credit application, administering this and any subsequent contract or credit arrangement with Te Huruhi Finance, and for marketing goods and services provided by Te Huruhi Finance, and I give my authorization for the use of this information for these purposes. I irrevocably authorize any third party to provide Te Huruhi Finance with such information as is required to assess my application for credit, and further authorize Te Huruhi Finance to provide this information, along with details of any subsequent or past dealings I may have with Te Huruhi Finance, to any third party, for like purposes. I agree to accept the terms sales as follows: 1) Payment is due by the 20th day of the month following purchase, except where otherwise agreed; 2) Interest may be charged on overdue amounts at the rate of 30% per annum calculated and compounded monthly; 3) Fees may be charged in the recovery of overdue debts; 4) Goods remain the property of Te Huruhi Finance until fully paid for; 5) Claims and requests for credit should be made within seven (7) days of invoice; 6) Returned goods may be subject to a 10% handling and restocking fee; 7) A credit administration fee may be charged to establish your account, and on individual credit purchases; 8) Revolving Credit and Fixed Term accounts are charged interest at the rate of 2% per month and 25% per annum respectively. I understand that failure to supply the specified information to complete this form may prejudice or preclude the favourable determination of my application for credit.

Upon submitting my application,
I consent to the terms as shown above.