MAS, FREEPOST 884, PO Box 13042, Johnsonville, Wellington. Phone 0800 800 627. Facsimile (04) 477 0109
This section to be completed on behalf of all Applicants Lender details Lender name Medical Securities Limited
Contact address 19–21 Broderick Road, PO Box 13042, Johnsonville, Wellington Contact phone 0800 800 627
Facsimile (04) 477 4847
Email address [email protected] Borrower details Full legal name
Physical address
Legal structure (tick one)
Individual (as sole trader or partnership) Trust
Company Contact details Contact name Postal address
Phone Work Home
Mobile Fax
Email Work Personal
Finance details Purpose of loan
Term of loan months/years
Initial loan structure
Facility type Fixed rate
period Amount Security provided (tick at least one)
a) Term loan – fixed rate 1 year $ Unsecured
2 year $ General Security Agreement
3 year $ Guarantee from
4 year $ limited to $
5 year $ and/or
b) Term loan – floating rate n/a $ Mortgage over property at: (Please detail address below)
c) Business Creditline – floating rate n/a $
Total finance requested $
Application for Business Finance
This personal information collected in relation to this loan application will be held by Medical Securities Limited (the “Lender”), and used only for the purposes of this application. Under the Privacy Act 1993, you have the right to access and correct any personal information held by the Lender.
Sole Trader/Partnership
Please tick which is relevant Sole trader Partnership Borrower details
Borrower 1 Full name Residential address
Postal address (if different from above)
Date of birth
Contact phone Work Home
Mobile Fax
If you are an existing MAS Member, please write your Member number here Borrower 2 Full name
Residential address
Postal address (if different from above)
Date of birth
Contact phone Work Home
Mobile Fax
If you are an existing MAS Member, please write your Member number here Borrower 3 Full name
Residential address
Postal address (if different from above)
Date of birth
Contact phone Work Home
Mobile Fax
Who needs to complete this section?
Borrower 4 Full name Residential address
Postal address (if different from above)
Date of birth
Contact phone Work Home
Mobile Fax
If you are an existing MAS Member, please write your Member number here Other
information required
please provide copies of
Business financials covering the last three years Statement of Financial Position
Valuation on any property offered as security If premises not owned, copy of current lease
If refinancing an existing loan, minimum last six months payment history of loan to be refinanced Business Plan
Disclosure and
acknowledgements I/we (“the applicants”) declare as follows:1. I/We have not been declared bankrupt.
2. I/We have not had any judgments entered against me/us.
3. I/We have not withheld any information on my/our financial position or commitments that might affect the decision of the Lender in respect of this application.
4. The application is the property of the Lender.
5. I/We agree to pay all costs, outlays and out-of-pocket expenses (including establishment fee, valuation, registration, stamp duty and legal costs) incurred by the Lender whether the advance is made by the Lender or not.
6. In making this application I/we authorise:
a. the use of the personal information held by the Lender for the purpose of mailing to me/us advice of any other products or services managed by or promoted by MAS.
b. the release at any time to the Lenders of all my/our personal information held by: a) any other credit providers and credit reference agencies and b) my/our previous or current employer(s) regarding my/our employment history and income.
c. the Lender to collect from any other person or organisation any personal information about me/us, which is connected with and is necessary to the evaluation of my/our borrowing from Medical Securities Limited, including its security and insurance risk.
d. the Lender to supply upon request details of this application or the outstanding balance to a guarantor or proposed guarantor.
Note – All Borrowers must sign below
Signature of Borrower 1 Date
Signature of Borrower 2 Date
Signature of Borrower 3 Date
Trusts
Who needs to complete this section?
If the Borrower is a TrustBorrower details – Trusts Trustee 1 Full name
Residential address
Postal address (if different from above)
Date of birth
Contact phone Work Home
Mobile Fax
If you are an existing MAS Member, please write your Member number here Trustee 2 Full name
Residential address
Postal address (if different from above)
Date of birth
Contact phone Work Home
Mobile Fax
If you are an existing MAS Member, please write your Member number here Trustee 3 Full name
Residential address
Postal address (if different from above)
Date of birth
Contact phone Work Home
Mobile Fax
Trustee 4 Full name Residential address
Postal address (if different from above)
Date of birth
Contact phone Work Home
Mobile Fax
If you are an existing MAS Member, please write your Member number here Other information required please provide copies of Trust Deed
Financial statements of the Trust for the last three years Business Plan
Business financials covering the last three years Valuation on any property offered as security If premises not owned, copy of current lease
If refinancing an existing loan, minimum last six months payment history of loan to be refinanced Disclosure and
acknowledgments I/we (“the applicants”) declare as follows:1. I/We have not been declared bankrupt.
2. I/We have not had any judgments entered against me/us.
3. I/We have not withheld any information on my/our financial position or commitments that might affect the decision of the Lender in respect of this application.
4. The application is the property of the Lender.
5. I/We agree to pay all costs, outlays and out-of-pocket expenses (including establishment fee, valuation, registration, stamp duty and legal costs) incurred by the Lender whether the advance is made by the Lender or not.
6. In making this application I/we authorise:
a. the use of the personal information held by the Lender for the purpose of mailing to me/us advice of any other products or services managed by or promoted by MAS.
b. the release at any time to the Lenders of all my/our personal information held by: a) any other credit providers and credit reference agencies and b) my/our previous or current employer(s) regarding my/our employment history and income.
c. the Lender to collect from any other person or organisation any personal information about me/us, which is connected with and is necessary to the evaluation of my/our borrowing from Medical Securities Limited, including its security and insurance risk.
d. the Lender to supply upon request details of this application or the outstanding balance to a guarantor or proposed guarantor.
Note – All Trustees must sign below
Signature of Trustee 1 Date
Signature of Trustee 2 Date
Signature of Trustee 3 Date
Companies
Who needs to complete this section?
All Directors of the Company
Borrower details – Companies Director 1 Full name
Residential address
Postal address (if different from above)
Date of birth
Contact phone Work Home
Mobile Fax
If you are an existing MAS Member, please write your Member number here Director 2 Full name
Residential address
Postal address (if different from above)
Date of birth
Contact phone Work Home
Mobile Fax
If you are an existing MAS Member, please write your Member number here Director 3 Full name
Residential address
Postal address (if different from above)
Date of birth
Contact phone Work Home
Mobile Fax
Director 4 Full name Residential address
Postal address (if different from above) Date of birth
Contact phone Work Home
Mobile Fax
If you are an existing MAS Member, please write your Member number here Other information required please provide copies of Certificate of Incorporation Business Plan
If premises not owned, copy of current lease
If refinancing an existing loan, minimum last six months payment history of loan to be refinanced Business financials covering the last three years
Valuation on any property offered as security Disclosure and
acknowledgments I/we (“the applicants”) declare as follows:1. I//We confirm that the Company is solvent in terms of Section 4 of the Companies Act 1993. 2. I/We have not been declared bankrupt.
3. I/We have not had any judgments entered against me/us.
4. I/We have not withheld any information on my/our financial position or commitments that might affect the decision of the Lender in respect of this application.
5. The application is the property of the Lender.
6. I/We agree to pay all costs, outlays and out-of-pocket expenses (including establishment fee, valuation, registration, stamp duty and legal costs) incurred by the Lender whether the advance is made by the Lender or not.
7. In making this application I/we authorise:
a. the use of the personal information held by the Lender for the purpose of mailing to me/us advice of any other products or services managed by or promoted by MAS.
b. the release at any time to the Lenders of all my/our personal information held by: a) any other credit providers and credit reference agencies and b) my/our previous or current employer(s) regarding my/our employment history and income.
c. the Lender to collect from any other person or organisation any personal information about me/us, which is connected with and is necessary to the evaluation of my/our borrowing from Medical Securities Limited, including its security and insurance risk.
d. the Lender to supply upon request details of this application or the outstanding balance to a guarantor or proposed guarantor.
Note – All Directors must sign below. If the Company only has one Director then a Witness must also sign below.
Signature of Director 1 Date
Signature of Director 2 Date
Signature of Director 3 Date
Signature of Director 4 Date
Signature of Witness Date
Guarantors
Who needs to complete this section?
All Guarantors for the loan
Borrower Details – Guarantors Guarantor 1 Full name
Residential address
Postal address (if different from above)
Date of birth
Contact phone Work Home
Mobile Fax
If you are an existing MAS Member, please write your Member number here Guarantor 2 Full name
Residential address
Postal address (if different from above)
Date of birth
Contact phone Work Home
Mobile Fax
If you are an existing MAS Member, please write your Member number here Guarantor 3 Full name
Residential address
Postal address (if different from above)
Date of birth
Contact phone Work Home
Mobile Fax
Guarantor 4 Full name Residential address
Postal address (if different from above)
Date of birth
Contact phone Work Home
Mobile Fax
If you are an existing MAS Member, please write your Member number here Other
information required
please provide copies of
Statement of Financial Position
Direct debit authority
MAS, FREEPOST 884, PO Box 13042, Johnsonville, Wellington. Phone 0800 800 627. Facsimile (04) 477 0109
Bank instructions
Name of Bank Account Holder (please print)
Membership number
Authority Customer to complete bank/branch number and account number and suffix of account to be debited.
Account number
Bank Branch Account number Suffix
Authority to accept Direct Debits
(Not to operate as an assignment or an agreement)
Authorisation code 0 6 0 9 9 3 3 Date
Bank Branch
I/We authorise you until further notice in writing to debit my/our account with you all amounts which Medical Assurance Society New Zealand Limited (hereinafter referred to as the Initiator), Head Office, PO Box 13042, Johnsonville, Wellington 6440, 19-21 Broderick Road, Johnsonville, Wellington 6037, Telephone 0800 800 627, Facsimile (04) 477-0109, the registered Initiator of the above Authorisation Code, may initiate by Direct Debit.
I/We acknowledge and accept that the Bank accepts this authority only upon the conditions listed overleaf.
Information to appear in my/our bank statement (to be completed by the Customer)
Payer particulars
Authorised signature
Date
Authorised signature
Date
For Bank use only Approved
00993 01 91
Date received Recorded by Checked by Bank stamp
Conditions of this Authority to Accept Direct Debits
1. The Initiator:
a) Undertakes to give written notice to the Acceptor of the commencement date, frequency and amount at least 10 calendar days before the first Direct Debit is drawn (but not more than two calendar months). This notice will be provided either:
i) in writing; or
ii) by electronic mail where the Customer has provided prior written consent to the Initiator. Where the Direct Debit system is used for the collection of payments which are regular as to frequency, but variable as to amounts, the Initiator undertakes to provide the Acceptor with a schedule detailing each payment amount and each payment date.
In the event of any subsequent change to the frequency or amount of the Direct Debits, the Initiator has agreed to give advance notice at least 30 days before changes come into effect. This notice must be provided either:
– in writing; or
– by electronic mail where the Customer has provided prior written consent to the Initiator. b) May, upon the relationship which gave rise to this Authority being terminated, give notice to the Bank that
no further Direct Debits are to be initiated under the Authority. Upon receipt of such notice the Bank may terminate this Authority as to future payments by notice in writing to me/us.
c) May, upon receiving an “authority transfer form” (dated after the day of this authority) signed by me/us and addressed to a bank to which I/we have transferred my/our bank account, initiate Direct Debits in reliance of that transfer form and this Authority for the account identified in the authority transfer form.
2. The Customer may:
a) At any time, terminate this Authority as to future payments by giving written notice of termination to the Bank and to the Initiator.
b) Stop payment of any Direct Debit to be initiated under this Authority by the Initiator by giving written notice to the Bank prior to the Direct Debit being paid by the Bank.
c) Where a variation to the amount agreed between the Initiator and the Customer from time to time to be direct debited has been made without notice being given in terms of clause 1 a) above, request the Bank to reverse or alter any such Direct Debit initiated by the Initiator by debiting the amount of the reversal or alteration of the Direct Debit back to the Initiator through the Initiator’s Bank, PROVIDED such request is not made more than 120 days from the date when the Direct Debit was debited to my/our account.
3. The Customer acknowledges that:
a) This Authority will remain in full force and effect in respect of all Direct Debits passed to my/our account in good faith notwithstanding my/our death, bankruptcy or other revocation of this Authority until actual notice of such event is received by the Bank.
b) In any event this Authority is subject to any arrangement now or hereafter existing between me/us and the Bank in relation to my/our account.
c) Any dispute as to the correctness or validity of an amount debited to my/our account shall not be the concern of the Bank except in so far as the Direct Debit has not been paid in accordance with this Authority. Any other dispute lies between me/us and the Initiator.
d) Where the Bank has used reasonable care and skill in acting in accordance with this Authority, the Bank accepts no responsibility or liability in respect of:
– accuracy of information about Direct Debits on Bank Statements.
– any variations between notices given by the Initiator and the amounts of Direct Debits. e) The Bank is not responsible for, or under any liability in respect of the Initiator’s failure to given written
advance notice correctly nor for the non-receipt or late receipt of notice by me/us for any reason whatsoever. In any such situation the dispute lies between me/us and the Initiator.
f) Notice given by the Initiator in terms of clause 1 a) to the debtor responsible for the payment shall be effective. Any communication necessary because the debtor responsible for payment is a person other than me/us is a matter between me/us and the debtor concerned.
4. The Bank may:
a) In its absolute discretion conclusively determine the order of priority payment by it of any monies pursuant to this or any other Authority, cheque or draft properly executed by me/us and given to or drawn on the Bank.
b) At any time terminate this Authority as to future payments by notice in writing to me/us. c) Charge its current fees for this service in force from time-to-time.
