Application Form – Pinnacle Wealth Solutions

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PO Box 204 Emu Park Queensland, AUS 4710

Mon - Fri 9.00 - 17.00 Sat/Sunday CLOSED

0438 460 860 FREE Consultation

Application Form

Step 1 of 5

20%

Are there 1 or 2 Applicants?*
- One Applicant
- Two Applicants
Please select number of Applicants
Applicant 1
Title
Surname
Given Names
Previous Names
Date of Birth
DD slash MM slash YYYY
Sex
- Male
- Female
Resident of (if not Australia)

Leave Blank if you are a resident of Australia
Marital Status
No. of Dependents

Total Number of Dependents
Ages

Ages of Dependents
Current Address
Street Address Address Line 2 Suburb State Postcode
Time At Current Address
Enter Number of Years
Time At Current Address
Enter Number of Months
Current Residential Status
Please Provide Previous Address
Street Address Address Line 2 Suburb State Postcode
Is Postal Address Different From Current Address?
- Yes
- No
Please Provide Postal Address
Street Address Address Line 2 Suburb State Postcode
Email Address
Home Phone Number
Work Phone Number
Mobile Number
Preferred Daytime Contact Number
- Home
- Work
- Mobile
Applicant 2
Title
Surname
Given Names
Previous Names
Date of Birth
DD slash MM slash YYYY
Sex
- Male
- Female
Resident of (if not Australia)

Leave Blank if you are a resident of Australia
Marital Status
No. of Dependents

Total Number of Dependents
Ages

Ages of Dependents
Current Address
Street Address Address Line 2 Suburb State Postcode
Years At Current Address
Enter Number of Years
Months At Current Address
Enter Number of Months
Current Residential Status
Please Provide Previous Address
Street Address Address Line 2 Suburb State Postcode
Is Postal Address Different From Current Address?
- Yes
- No
Please Provide Postal Address
Street Address Address Line 2 Suburb State Postcode
Email Address
Home Phone Number
Work Phone Number
Mobile Number
Preferred Daytime Contact Number
- Home
- Work
- Mobile

Applicant 1 - Employment Details:
Employment Status
- PAYG Employee
- Self Employed
- Family Business
- Full Time
- Part Time
- Casual
- Contractor
- Temporary
- Home Duties
- Retired
- Student
- Not Employed
- Govt. Benefit Recipient
- Other
Select all that apply
Other

Please give more details on 'Other' Employment Status
Occupation
Employment Sector or Nature of Business
Employer/Company Name and Address
Street Address Address Line 2 Suburb State Postcode
Employer Contact Name & Phone Number

Human Resources / Payroll Contact
Employer Email
Years At Current Employment
Enter Number of Years
Months At Current Employment
Enter Number of Months
Average Hours Per Week

If Working Casual or Part Time
Previous Occupation and Industry
Previous Employment Status
- PAYG Employee
- Self Employed
- Family Business
- Full Time
- Part Time
- Casual
- Contractor
- Temporary
- Home Duties
- Retired
- Student
- Not Employed
- Govt. Benefit Recipient
- Other
Select all that apply
Other

Please give more details on 'Other' Previous Employment Status
Previous Employers Name and Address
Street Address Address Line 2 Suburb State Postcode
Years At Previous Employment
Enter Number of Years
Months At Previous Employment
Enter Number of Months
Applicant 2 - Employment Details:
Employment Status
- PAYG Employee
- Self Employed
- Family Business
- Full Time
- Part Time
- Casual
- Contractor
- Temporary
- Home Duties
- Retired
- Student
- Not Employed
- Govt. Benefit Recipient
- Other
Select all that apply
Other

Please give more details on 'Other' Employment Status
Occupation
Employment Sector or Nature of Business
Employer/Company Name and Address
Street Address Address Line 2 Suburb State Postcode
Employer Contact Name & Phone Number

Human Resources / Payroll Contact
Employer Email
Years At Current Employment
Enter Number of Years
Months At Current Employment
Enter Number of Months
Average Hours Per Week

If Working Casual or Part Time
Previous Occupation and Industry
Previous Employment Status
- PAYG Employee
- Self Employed
- Family Business
- Full Time
- Part Time
- Casual
- Contractor
- Temporary
- Home Duties
- Retired
- Student
- Not Employed
- Govt. Benefit Recipient
- Other
Select all that apply
Other

Please give more details on 'Other' Previous Employment Status
Previous Employers Name and Address
Street Address Address Line 2 Suburb State Postcode
Years At Previous Employment
Enter Number of Years
Months At Previous Employment
Enter Number of Months

Your Financial Position
Assets and Liabilities
Principal Home
Applicant
Value

Home Value
Mthly Repayment

Monthly Home Loan Repayment
Amount Owing

Amount Owing on Home Loan
Lender

Bank or Financial Institution
Investment Property
- YES
- NO
Do You Have Investment Property?
Investment Property
Applicant
Value

Investment Property Value
Mthly Repayment

Monthly Home Loan Repayment
Amount Owing

Amount Owing on Home Loan
Lender

Bank or Financial Institution
Any More Investment Property?
- YES
- NO
Do You Have Other Investment Property?
Investment Property 2
Applicant
Value

Investment Property Value
Mthly Repayment

Monthly Home Loan Repayment
Amount Owing

Amount Owing on Home Loan
Lender

Bank or Financial Institution
Motor Vehicles
Applicant
Value

Market Value of Vehicle
Mthly Repayment

Monthly Vehicle Loan Repayment/s
Amount Owing

Amount Owing on Vehicle/s
Vehicle Make
Vehicle Model
Vehicle Year
Lender

Bank or Financial Institution

Financial Position continued...
Assets
Investments
Shares, Managed Funds, Term Deposits
Applicant
Value

Total Value of Investments
Cash
Including Savings
Applicant
Value
Superannuation
Applicant
Value
Home Contents
Insured Value
Applicant
Value

Insured Value
Other Assets
Boats, Caravans, Art Collections, etc.
Applicant
Value

Total Value

Financial Position continued...
Liabilities
Credit Cards & Retail Store Cards
Total combined limits
Applicant
Limit

Card Credit Limit
Lender

Bank or Financial Institution
Personal Debt
Personal Loans
Applicant
Amount Owing
Lender

Bank or Financial Institution
HECS / Taxation Debt
Education and Tax Debts
Applicant
Amount Owing
Other Liabilities
Please give details of any other debts
End of Application Form
Final Comments
Any other comments you would like to make regarding this application.

how can we help you?

Have a question, feedback or require financial advice, the please Contact Us.

Tony Beardmore

Tony Beardmore

Anthony Beardmore is a credit representative (Credit Representative Number 399805) of BLSSA Pty Ltd (Australian Credit Licence No. 391237)

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