Rental & 14 Day Account Application Form
- Please complete and submit this form. The more information you can provide the faster your application can be processed.
Title
Please select one...
Mr
Mrs
Ms
Dr
Full Given Names
*
:
Surname
*
:
Date of Birth
*
(DD/MM/YYYY):
Current Address
*
:
City/Suburb
*
:
P/Code:
State:
Email:
Phone No
*
:
Mobile:
Facsimile:
Occupation:
Employer/Business Name:
ABN:
Date Started:
Phone No:
Mobile:
Fax:
Landlord Name:
Landlord Phone No:
Business References
(Please list companies you have conducted business with)
*
:
Business Name:
Address:
Phone:
Fax:
Mobile:
Business Name:
Address:
Phone:
Fax:
Mobile:
Personal
References
(These can be friends, relatives or work colleagues)
*
:
Name:
Address:
Phone:
Name:
Address:
Phone:
Name:
Address:
Phone:
Car Registration No.:
Form of ID
*
:
Please select one...
Business Card
Credit Card
Drivers License
Government Dept
ID Card
Key Card
Known Personally
ID Reference
*
:
Expiry Date
*
:
*
I/We declare that the personal information provided to VERSACOM may be used by VERSACOM to seek a credit reference on me/us. I/We consent to VERSACOM providing information, including personal details to identify me/us, in accordance with the provisions of the Privacy Act 1988
*
Required fields
