Fill in the online form below to submit your application to Provincial Home Loans.
Please be sure to print and complete the Confidentiality Agreement, and fax
it to (03) 8612 4932.

Fields in bold are required.

The information you provide in this application will be treated in the strictest confidence. It will also be used to prepare your agreement should your application be successful. Please provide full and correct details.

Who/what directed you to this site to fill in this application?
If it was a current licensee, please state name. If it was an adverisment, please state publication.

 
Your Details
Title:
Given Name:
Middle Name(s):
Surname:
Street Address:
Town / Suburb:
Postcode:
Mobile Number:
Phone Number:
Fax Number:
Email:
Please do not use a web based email such as hotmail
Date of Birth:
Driver's Licence #:
Company Name
(if applicable):

Only Pty Ltd Companies, not trading names
ACN:
ABN:
Are you currently or have you ever worked as a Mortgage Originator?
 
If Yes, who with and how many residential housing loans would you obtain approval for each month?
 
Summary of Experience:

Employment History:


List most current first, and at least last 7 years.
Business References
  Written references WILL be required for accreditation purposes should you be successful.
Please be prepared to provide these when asked.
We may also contact your referees by phone.
  Name Number
1
2
3

Computer Requirements

 


Listed below are the minimum Computer Requirements. Typing Yes in this box indicates that you have or have access to these requirements.
 
  • Pentium 166 processor or greater with a minimum of 32 Meg of RAM and a 3 Gig Hard Drive and compatible printer.
  • 56k Modem.
  • Be connected to the Internet and have e-mail with the facility to receive attachments.
  • Microsoft Office 97 or later.
  • Adobe Acrobat Reader to be able to read pdf type documents
  • WinZip or equivalent program to open compressed files.
  • Sharp EL735 Calculator
Company / Partnership Information
Company /
Partnership
Name 		Type of
Operation 		Percentage
Owned		 App. Date
Acquired /
Created
 1  %
 2  %
 3  %
 4  %
 5  %

If "Yes" to any of the following questions, please provide details

After you submit this application you will be asked to sign our confidentaility agreement and a Statutory Declaration stating that the information you provide below is true and correct.
During the past 5 years have your or, in the case of a company, any other Director(s) ever

i) Had an insurance refused, cancelled, declined or had any special conditions imposed?
.


.
ii) Been declared bankrupt, subject to any form of insolvency administration (eg liquidation or receivership)?
.


.
iii) Been convicted of a criminal offence?
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.
iv) Had a default or judgement lodged against you or any Company you are a Director of?
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v) Is pending or has been the subject of any investigation or enquiry by or on behalf of any Stock Exchange / Government Department / Securities Commission / Bank / Financial or Lending Institution / Banking ombudsman / or similar regulatory or investigatory body?
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vi) Been prosecuted under the Trade Practices Act, New Consumer Credit Code, Companies Act, Crimes Act or any other legislation?
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vii) Have you been refused accreditation by a Lender?
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Fields in bold are required. Please do not put TBA or other comment implying that you will advise later. It will only delay your application, as it will not be processed until it is complete.

  

This application must be accompanied by our Confidentiality Agreement.
.

© 2002-2004 Provincial Home Loans Pty Ltd ACN 059 654 394
PO Box 655
Drysdale VIC 3222
Fax 03 8612 4932
support@provincialhomeloans.com.au