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Application Form

BETWEEN: CREDIT REPAIR AUSVENGERS (PROVIDER) AND
Client *
Address *
PLEASE ANSWER ALL QUESTIONS AND TICK CORRECT RESPONSES
Surname *
Middle Name
First Name *

Have you used a credit repair agency before *

 
YesNo
If yes, name of Institution
How did you find us *
Email *

Have you ever used another name *

 
YesNo

Any other surname you have used

 

Any other first name used

 
Sex *
MaleFemale
Date of Birth *

Do you currently hold a drivers licence *

 
YesNo

Current drivers licence number

 

Previous drivers licence number

 

Daytime Contact Number

Home
Work
Mobile *

Name of previous employer

 
Employment

Are you currently employed *

 
YesNo

Name of current employer

 
Self Employed
Business Name

Name of the company who you last applied for credit e.g. Name of bank or credit union

 
Address

Current residential address *

 

Previous residential address*

 

Additional previous address

 

Are you currently bankrupt or in a Part debt agreement *

 
YesNo
Court Judgements/Black Marks

Please list defaults/court judgements on your credit file: (If you are unaware of these listings an estimate is fine)

Amount
Company
Amount
Company
Amount
Company
Amount
Company

Please enter your full name

Signed by Client *
Date *
By signing you are agree to the terms and conditions, your on line signature is the same as your original signature and is binding to this contract.