1 About your purchase2 More about you3 Financial situation4 Privacy consent About your purchaseFinance For*Vehicle Purchased from Paul Kelly Motor CompanyOtherMake*Model*About the LoanPurchase Price*DepositLoan AmountAbout YouTitle*MrMrsMissDrProfFirst Name*Middle NameLast Name*Date of birth* DD MM YYYY New Zealand residency status*NZ CitizenResidentWork PermitEmail address* Phone number*Relationship status*MarriedDe factoSingleSeperated Personal DetailsLiving situation*Select...OwnRentBoardLiving with parent/guardianOtherCurrent address*Time at current address*YearsTime at current address*1 Year2 Years3 Years4 Years5 YearsOver 5 YearsTime at current address*1 Month2 Months3 Months4 Months5 Months6 Months7 Months8 Months9 Months10 Months11 Months12 MonthsMonthsPrevious addressTime at previous addressYearsMonthsMortgage or rent payments*Frequency*WeeklyFortnightlyMonthlyDriver's licence*Select...Full LicenceRestricted LicenceLearner LicenceOverseas LicenceNoneLicence number*Version number (section 5b)*Expiry date*Number of dependants under 18*Name of nearest relative*Their relationship to you*Their address*Their phone number*Employment detailsEmployed*Select...Full timePart timeSelf employedOtherOccupation*Employer*Employer address*Employer phone*Previous employerPrevious employer addressPrevious employer phoneTime at current job*YearsMonthsNet Income*Income Frequency*Select...WeeklyFortnightlyMonthly Assets and liabilitiesCash in BankVehiclesBoatsHire purchasesPersonal loanCredit cardOtherAdditional notesPlease inform us of any other relevant information ConditionsHave you ever had or are there now any attachments or legal proceeding against you, or any action for payment default?YesNoIf yes, please state detailsInformation Statement/Authorisation Pursuant To The Privacy Act 1993 Please read this statement/authorisation notice in full. Where the applicant is a limited liability company, this authority and acknowledgement applies to all directors of that company. I/We understand that I am/we are not required to provide any personal information to the dealer/broker named in this application for finance (application), but that failure to do so may prejudice my/our chances of obtaining finance. I/We certify that the information in this application is true and correct, and that I am/we are over the age of 18 years and I am/we are not an undischarged bankrupt(s). I am/We are aware that the information in this application is collected initially for the purpose of considering my/our application for finance, and may be given to a number of lender's at the discretion of the dealer/broker. If this application is approved, I/we understand that the information will be used by the lender for the purpose of administering the loan. I/We agree that the lender may send me/us details of other products and services from time to time and may use all personal information held about me/us for the purpose of considering any future application for finance made by me/us and/or offering me/us further financial accomodation. By completing this application I/We authorise the dealer/broker and/or lender; - to collect from credit reporting agencies, credit providers, my/our employer(s), accountant(s) or other named persons, such personal, financial and commercial information and references about me/us as is necessary for the purpose of considering this application, and for those third parties to disclose information to the dealer/broker/and or lender; - to disclose personal information about me/us to credit reporting and debt collection agencies in the event of any default in any sum owing to the lender, and also to any third party making an authorised enquiry about me/us. I/We understand that, pursuant to the Privacy Act 1993, I/we have the right to request access to and correction of any personal information held by the dealer/broker. I have read and accept the terms and conditions within this informative statement/authorisation. * I accept the Terms And Conditions CAPTCHAPlease ensure the details you have provided above are correct before submitting the application. This iframe contains the logic required to handle Ajax powered Gravity Forms.