Agreement between Credit Mend Australia Pty Ltd.ACN 643 405 707 &
Is this application being made in a company name? YesNo
Name of Company
ACN Number
Are you currently employed?* YesNoSelf Employed
Name of Current Employer*
Please Provide Name of Your Business*
Consultants Name*
First Name*
Middle Name
Surname*
Phone Mobile*
Phone Work
Email Address*
Confirm Email Address*
Date of Birth*
- - - Select Date - - -01020304050607080910111213141516171819202122232425262728293031
- - - Select Month - - -JanFebMarAprMayJunJulAugSepOctNovDec
- - - Select Year - - -194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002
Confirm Date of Birth*
- - - Confirm Date - - -01020304050607080910111213141516171819202122232425262728293031
- - - Confirm Month - - -JanFebMarAprMayJunJulAugSepOctNovDec
- - - Confirm Year - - -194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002
Gender* MaleFemale
Current Residential Address*
- - - Select State - - -QLDWASAVICTASNTNSWACT
Have you been at this address less than 3 years? YesNo
Previous Residential Address*
Have you used a credit repair agency before?* YesNo
Name of Institution*
Please provide name of the consultant you were dealing with*
Do you currently hold a drivers licence?* YesNo
Drivers Licence*
Passport Number*
Are you currently bankrupt or in a Part 9/10 debt agreement?* YesNo
Terms and Conditions*
Credit Mend Australia Pty Ltd.Terms & Conditions
By completing your online signature you are agreeing to the terms and conditions on this page and understand this is the same as an original signature and is binding.
Term And Conditions
You acknowledge and agree:
Authorisation of Authority to Credit Mend Australia:
You are over the age of 18 years;
Payment for the removal of a negative listing is required irrespective of whether you chose to terminate this agreement prior to the negative listing being removed. You acknowledge that Credit Mend Australia undertakes the services upon agreement of these terms and conditions. Therefore, the removal fee becomes due and payable on the date the confirmation of removal is received in writing by the debt collector, creditor, plaintiff.
This agreement will be terminated and you will not be eligible for a full or partial refund if you do not respond to Credit Mend Australia’s attempts to contact you via phone calls, SMS or letters for greater than 30 days: or as per the resolution agreement and or requests from the associated debt collector, creditor, plaintiff.
Signature*
Date*
By ticking this box you are here by accepting the above terms and conditions on this agreement page and understand that this signature acts as a normal signature and is legally binding.*
Your details are kept confidential
9876 West Green Street
Phone: 1-800-987-6543
Mobile: 1-800-345-6789
Email: info@your-domain.com
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