Business Type (Broker, Dealer, other)
Registered for GST?
Head Office Address
Position in organisation/Company position
Number of locations
Number of Sales Representatives
Product lines to be financed
Average dollar value of equipment
Size and brief explanation of Customer Base
Referee 1 Name
Referee 2 Name
In relation to the past ten (10) years:
Have you ever had a business related licence or registration revoked, denied or suspended?
Have you ever had a lender accreditation or industry membership revoked, denied or suspended?
Have you ever been convicted of an offence involving criminal charge, or is there any charge pending?
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?
Have you ever been refused membership of a statutory, professional or other body in respect of your professional capacity?
Are you currently the Director/Owner?
I accept and consent to the