Lombard Finance Retail Partner Application Form

Company Details

_{Trading Name:*}			_ABN:*
_{Business Name:*}		_Website:
_{Primary Business Location}
_Number:*	_Street:*	_Suburb:*	_State:*	_Postcode:*
_{Postal Address}
_Number:	_Street:	_Suburb:	_State:	_Postcode:
_{Phone Number:*}	_{Fax Number:}	_{Director(s) Email Address:*}
_{Underwriting Approvals (Email and/or Fax Address):}		_{Disbursement Confirmations (Email and/or Fax Address):}
_{Time in Business Years:* Months:*}	_{If Less than Three Years Details of Prior Business:}		_{Previous Business ABN:}
_{Is Annual Turnover Greater than $500,000:*} Yes No	_{Estimated Weekly Turnover with Lombard:*} $	_{Average Sale Value:*} $
_{Have any owner(s)/Director(s) or company officers ever been covered by bankruptcy orders, or been associated with organisations that have been bankrupt or insolvent?:*} Yes No		_{If Yes, Please give details:}

Details of Registered Owner(s)/Director(s)

Business References (Major Supplier)

_{Trade Reference}
_{Name of Business:*}	_{Person to Contact:*}	_Phone:*
_{Accountant Reference}
_{Name of Accountant:*}	_{Person to Contact:*}	_Phone:*
_{Are you a member of an Industry Association or Buying Group, if Yes give details:}

Fund Distibution

Funds will be directly credited to an account of your choice. Please nominate your preferred Account

_{Name of Account:}

_Bank:

_Branch:

BSB:

Account:

Establishment Fee

An establishment fee of $330 is required to activate your account.

Disclaimer

Yes No