Home Online Application Form
  You can start your application on line by completing this application form. On receipt we will process your application and contact you to confirm the products you desire. The application is on a secure site, your information will only be used for the purpose of the application and will also be shared with the credit process provider.
 
Personal Information  
First name *
Middle Name
Surname *
Date of Birth*
   
Email Address *
License No
Home No
Mobile No *
Work No
   
Residential Information
Street *
Suburb *
Post Code *
State
Period at Address *
If less than 12 months previous address
Street
Suburb
Post Code
Period at Address
   
Employment Information
Are you currently Employed *
Yes No
For the purpose of the application do you give RR permission to contact your employer to confirm employment
Yes No
Employers Name
Employers Address
Contact Number
Contact Name
   
Credit Information
Have you ever been bankrupt *
Do you have any outstanding debts that are default in nature
Yes No
As per the privacy act of 1998 do you give us permission to carry out a credit check for the purpose of this application.
   
References

3 references are required, one relative and two friends

Reference 1  
Relationship *
Full Name *
Contact Number *
Address
Reference 2  
Relationship *
Full Name *
Contact Number *
Address's
Reference 3  
Relationship *
Full Name *
Contact Number *
Address
Comments
 

Rental Program Required

Select products from the following table
Fridges Washing Machines Televisions
Medium Fridge 212 to 253L
Large Fridge 260 to 340L
Extra Large Fridge 390 to 422L

4.5 - 5.0 Kg Washing Machine
5.5 - 6.0 Kg Washing Machine
Extra Large 7.5 Kg plus

Dryers Freezers Computer
Entertainment Other Products  
Microwave Oven  
 
   
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