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CONTACT DETAILS

Full Name:*
Current Residential Address:
Previous Residential Address:
Telephone: *	(Business:) (Home:)
Fax No:
Email Address: *
Registered Office (if a Company):
ACN/ABN (if applicable):
Trading Name (if applicable):
Date of Birth: *
Place of Birth: *

LEASE DETAILS

Shop No: *
Proposed Business:
Proposed Assignment / Lease Commencement Date:
Current Rental:
Current Outgoings:
Lease Term / Remaining Term:
Options:
Rent Reviews:
Guarantors (if applicable)
Full Name:
Address:

LEASING / BUSINESS AGENT

Name of Company: *
Representative:
Address: *
Telephone Number: *
Facsimile Number: *
Statement of Assets & Liabilities as at:

Note:
1. If Assets/Liabilities are held jointly, then only that proportion relating to the party making the Declaration is to be included.
2. Address of any property is to be given.

LIABILITIES

Owning on house to: *	$
Owning on other dwellings:*	$
Owning on vacant land to: *	$
Owning on Motor Vehicle to: *
1-*	$
2-	$
3-	$
Owning on Furniture to: *	$
Overdraft with: *	$
Other loans with: *
1-*	$
2-	$
3-	$
Other: *
1-*	$
2-	$
3-	$
Credit Card: *
1- (Credit Limit)*	$
2- (Credit Limit)	$
3- (Credit Limit)	$

ASSETS

House at: *	$
Other dwellings at:*	$
Vacant land at: *	$
Motor Vehicle : *
1-*	$
2-	$
3-	$
Furniture: *	$
Cheque Account with: *	$
Saving Account with: *
1-*	$
2-	$
3-	$
Life Insurance(F/V) approx (A/V): *	$
Shares: *	$
Other Assets (eg. Boat,Jewelry,etc): *
1- *	$
2-	$
3-	$

Total Assets	$
Deduct Total Liabilities	$
Surplus Assets Over Liabilities	$

CREDIT CHECK AUTHORITY

By ticking this box I/We, the aforementioned, hereby give authority to Cockles Pty Ltd to conduct a check of my/our credit records and to make whatever other enquiries that are necessary to properly assess this application.