Business Type (Broker, Dealer, other):
ABN:
Business Name:
Head Office Address:
Business Telephone
Contact Name:
Mobile:
Email:
Website:
Number of locations: Years Established: Number of Sales Representatives:
Product lines to be financed:
Average dollar value of equipment:
Size and brief explanation of Customer Base:
Referee 1 Name:
Telephone:
Referee 2 Name:
I/We acknowledge that I/We will not knowingly be involved in submitting fraudulent finance applications.
I/We acknowledge that we have taken all reasonable steps to identify customers applying for finance.
In relation to the past ten (10) years:
Have you ever had a business related licence or registration revoked, denied or suspended? YesNo
Have you ever had a lender accreditation or industry membership revoked, denied or suspended? YesNo
Have you ever been convicted of an offence involving criminal charge, or is there any charge pending? YesNo
Are you or have you ever been a Director of a company which has gone into voluntary liquidation, or to which a Receiver, a Provisional Liquidator, a Scheme Manager or an Official Manager has been appointed while you were a Director, or within six (6) months after you ceased to be a director? YesNo
Have you ever been refused membership of a statutory, professional or other body in respect of your professional capacity? YesNo
Pursuant to SS.18K(1) and 18N(1) of the Privacy Act of 1988 and paragraph 2.12 of the Credit Reporting Code of Conduct issued under S.18A of that Act, you hereby agree to Relion Finance obtaining personal information from a credit reporting agency or a credit provider for the purposes of assessing this application for accreditation and agree to that agency providing that information to Relion Finance for that purpose.
I/We declare all information provided herein to be true and correct:
Name:
Date:
Please fax completed form and documents to : 02 8212 5888 or email to: apply@relionfinance.com.au
PHONE: 1300 21 22 23 | PO BOX 220 ERSKINEVILLE NSW 2043 | ACN 151 816 849 | www.relionfinance.com.au
