Please fill in the following application form
or if you prefer
click here to print off a form and fax to 09 441 7819
or post to

121 Finance Ltd
P.O.Box 100 482
North Shore
North Shore City 0745

Loan Amount Required*
Purpose of Loan
Car Finance
Personal Loan
Debt Consolidation
Other
If Other, please specify
Security *Must be owned by applicant/s. Vehicle must be 1993 or newer.*
If applicable: total amount secured against property
Registration No, or Address of Security.*
MAIN BORROWER
First & Middle Names
Surname
Date of Birth
Phone Home
Phone Work
Mobile
Email
CO BORROWER (if applicable) Full name and date of birth
Best time and phone number to contact you on
NZ Resident	Yes No (if no, will require a co-borrower who is a permanent resident.
Current Address
Status	- Please select - RENT BOARD OWN
Occupation Current
Employer Current
Average Net Income (after tax)
Commments / Questions
I accept the privacy act acknowledgement and authorisation below
YES
Type verification image:
*Required Fields

PRIVACY STATEMENT

121 FINANCE LTD IS COMMITTED TO PROTECTING YOUR PRIVACY AND MAINTAINING SECURITY OF THE INFORMATION YOU PROVIDE TO US. WE ABIDE BY THE LAWS RELATING TO PRIVACY AND SAFEGUARDING OF INFORMATION. OUR ON-LINE APPLICATION SERVICE IS A SECURE SITE FACILITY, MAINTAINING CONFIDENTIALITY OF CUSTOMER INFORMATION AT ALL TIMES.

PRIVACY ACT – PERSONAL INFORMATION NOTICE AND DECLARATION *

I/We declare that:

• I/We have read and understood this application and certify that the information provided is true and correct in all respects, and that I/We am/are no less than 18 years of age, and I/We am/are not an undischarged bankrupt.

• I have also disclosed any other names that I am currently known under.

• I/We are aware that if we have deliberately provided false information in this application, I/we could face fraud or dishonesty charges in the Courts.

Privacy Act Acknowledgement and Authorisation

	Question/Acknowledgement
1.	You understand that 121 Finance Ltd are asking for personal information about you to use Veda Advantage Ltd’s ("Veda") Credit report service to credit check you
2.	You understand Veda will give us personal information about you
3.	You understand we will give your personal information to Veda and they will hold that information and use it to provide their credit reporting service
4.	You understand that when other Veda customers use the Veda credit reporting service, Veda may give that information to them
5.	You understand 121 Finance ltd may use Veda in future for purposes related to the provision of credit to you. This may include Veda’s monitoring services to receive updates if any information about you changes.
6.	You understand that if you default in your payment obligations to us, information about that default may be given to Veda and Veda may give information about your default to other Veda customers
7.	Do you consent to us obtaining a credit report? (Note: if you do not consent your loan will not be able to be considered by 121 finance ltd)

Pursuant to the Privacy Act 1993 I authorise 121 Finance Ltd or any referring broker or motor vehicle dealer to contact Veda Advantage Limited, Credit Providers, Finance Companies, my Employer, Accountant, Bank, Solicitor or any other source including Government agencies, to obtain, check and exchange (both now and in future) such personal financial and commercial information for the purposes of considering this or any subsequent application, the protection and administration of any loan arising of this application (both now and in the future) and to assist in the enforcement of any agreement between myself and 121 Finance Limited.

I understand I have the right to know who is collecting and holding information and also the right to have access to it and to correct if it is wrong. The contact details for 121 Finance and Veda Advantage Limited are as follows:

121 Finance Ltd  PO Box 100482 North Shore Mail Centre www.121finance.co.nz

Veda Advantage Limited Private Bag 92156, Victoria Street Auckland www.mycreditfile.co.nz

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