Lombard Visa Card Application Form

Store Name (if applicable):

Store Location (if applicable):

Limit Requested:*

Personal Details

_{Applicant 1 First Name:*}	_{Middle Name:}	_{Last Name:*}	_{Date of Birth:*}
_{Applicant 2 First Name:}	_{Middle Name:}	_{Last Name:}	_{Date of Birth:}

_{Home Phone:*}

_{Mobile Number (Applicant 1):}

_{Mobile Number (Applicant 2):}

_Email:*

_{Mothers Maiden Name:}

_{Marital Status:*}

_{# of Dependants:*}

Residential Details

_{House #:*}

_Street:*

_{Suburb/State:*}

_Postcode:*

_{Years:* Months:*}

_{Living Status*}
Owned
Buying
Renting
Parents
Boarding

_{Landlord/1st Mortgage Holder}

_Phone:

_Location:

_{$ Amount:}

_per:

_{1st Mortgage Balance:}

_{Estimated Value:}

_Equity:

Previous Address if current address under 3 years)

_{House #:}

_Street:

_Suburb:

_State:

_Postcode:

_{Years: Months:}

_{Renting/Buying:}

Employment Details (3 years minimum history required)

Applicant 1 - Current Employer
_{Current Employer:*}	_Location:*	_Phone:*	_Occupation:*	_{Full/PartTime/Casual*}	_{Years* Months*}
Applicant 2 - Current Employer
_{Current Employer:}	_Location:	_Phone:	_Occupation:	_{Full/PartTime/Casual}	_{Years: Months:}
Applicant 1 - Previous Employer
_{Previous Employer:}	_Location:	_Phone:	_Occupation:	_{Full/PartTime/Casual:}	_{Years: Months:}
Applicant 2 - Previous Employer
_{Previous Employer:}	_Location:	_Phone:	_Occupation:	_{Full/PartTime/Casual:}	_{Years: Months:}

Income Details (if self employed, please provide name and phone # of your accountant)

_{Applicant 1 - Take Home Pay:*}

_per:*

_{Applicant 1 - Additional Income:}

_{Household Living Expenses:*}

_per:*

_{Applicant 2 - Take Home Pay:}

_per:

_{Applicant 2 - Additional Income:}

_{Government Family Allowance:}

_per:

_{If Self Employed - Accountant's Name:}

_{Accountant's Telephone Number:}

Motor Vehicle Details

_Year:

_Make/Model:

_{Finance Provider:}

_Balance:

_Repayment:

_Per:

Credit Card Details

_Lender:	_Limit:	_Balance:	_Payment:
_Lender:	_Limit:	_Balance:	_Payment:

Please Show All Other Loan Commitments

_Lender:	_Purpose:	_Balance:	_Payment:
_Lender:	_Purpose:	_Balance:	_Payment:

Identity Verification

1st Applicant:
_{Primary ID Document Type:*}	_{Document Number:*}	_{Place of Issue:}	_{Expiry Date:*}
_{Secondary ID Document Type:*}	_{Document Number:*}	_{Place of Issue:}	_{Expiry Date:*}

2nd Applicant:
_{Document Type:}	_{Document Number:}	_{Place of Issue:}	_{Expiry Date:}
_{Secondary ID Document Type:}	_{Document Number:}	_{Place of Issue:}	_{Expiry Date:}

Personal References (2 relatives not living with you)

_Name:*	_{Relationship:*}
_Address:*	_Phone:*
_Name:*	_{Relationship:*}
_Address:*	_Phone:*

Disclaimer

By submitting this application, I/we declare that the information in this application is true and correct, that I am a permanent Australian resident and have never been declared bankrupt and that I/we agree to the terms of the Privacy Statement and Consent. Click here for The Privacy Act and Consent.
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