Tenancy Application Form - Fisk & Nagle

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Tenancy Application Form
For your application to be processed you must answer all questions
(including the reverse side)
A. AGENT DETAILS
WHERE DID YOU FIND OUT ABOUT THIS PROPERTY?
Fiske & Nagle First Choice Real Estate
Newspaper
the Internet
Local Paper
Board
Counter List
Relocation Company
tick
*Please
appropriate office *
Referral
Other (Please specify):___________________________
Merimbula - 25389
Cooma - 25386
.au
.au
Fax: 02 6495 3154
Fax: 02 6452 4154
Shop 4, The Promenade,
Centennial Plaza,
D. FREE UTILITY CONNECTION SERVICE
Market Street,
114 Sharp Street,
Merimbula NSW 2548
Cooma, NSW 2630
Veda Connect
User consent form
Bega - 25387
Eden - 25385
.au
.au
Fax: 02 6492 5094
Fax: 02 6496 3490
Free Connections Service
Phone 1300 301 001
226 Carp Street
177 Imlay Street
Bega NSW 2550
Eden NSW 2551
Veda Connect is the hassle-free connections service that
takes the time and worry out of moving.
Property Manager
Cleaners
B. PROPERTY DETAILS
Water
Telephone
Electrical
1.
What is the address of the property you would like to rent?
Appliances
Removalist
Insurance
Gas
By signing this application, I/we give consent to Veda Connect to
Postcode
make contact by phone, email or sms for the purpose of arranging
connections & disconnections of approved utility services. I/we
2.
Property Rental
authorise Veda Connect to supply collected information to other
household servie providers for the services including Cleaning,
$
$
$
Per
Per.
Week
Month
Bond
Removal, Insurance & Appliances.
3.
Lease commencement date?
I/we
acknowledge
that
all
information
supplied
in
the
Day
Month
Year
application is true and correct to be best of my/our knowledge & that
4.
Lease term?
we have not falsely represented our identity in any manner.
Years
Months
I/we authorise Veda Connect to contact us via these means even if the
telephone numbers supplied are listed on the Do Not Call Register. I/
5.
How many tenants will occupy the property?
we understand that Veda Connect may also send related emails
Adults
Children
Ages
promoting other services provided by Veda Connect.
________________________
C. PERSONAL DETAILS
I/we understand that Veda Connect treat any personal information it
6.
Please give us your details
collects, uses or discloses in accordance with the Privacy Act 1988.
Mr.
Ms
Miss
Mrs.
Other
I/We authorise Veda Connect to supply collected information to
Surname
Given name/s
nominated suppliers and/or potential suppliers for the connection and
disconnection of nominated utilities or to assist with my obtaining other
services including applicanes, removalists, cleaners and insurance
Driver’s Licence Number
Date of Birth
I/we understand that in the course of connecting utilities, Veda
Connect may need to obtain an NMI (National Meter Identifier) for
Driver’s licence expiry date
Driver’s licence state
electrical points or MIRN (Meter Installation Registration Number) for
Natural Gas connections. I/we authorise VEDA CONNECT to collect
these identifiers and consent to those numbers being supplied to
utility providers.
Passport no
Passport country
I/We acknowledge that whilst Veda Connect is a free service, I/we are
solely responsible for any and all amounts payable in relation to
Pension no. (If applicable)
Pension type (if applicable)
deposits, connections/disconnections or ongoing supply of the
connected services and amounts payable for other services including
applicance, removalist, cleaners and insurance
7.
Have you been convicted of a criminal offence?
Yes
No
I/we acknowledge that Veda Connect, to the extent permitted by law,
shall not be liable for any loss or damage (including consequential loss
8.
Have you ever had a matter against you taken to the Consumer
Trader and Tenancy Tribunal?
and loss of profits) to me/us as a result of the provision of any service.
Yes
No
Nor shall Veda Connect be liable for any act or omission by any utility
provider for any loss caused by failure to provide nominated services.
9.
Please provide your contact details
Home phone number:
Mobile phone number:
I/we acknowledge that the nominated real estate entity along with
Veda Connect may receive a benefit from suppliers for the provision
of connections.
Work phone no.
Fax no.
I/we declare that we have read and understand the above
Email address
declaration and wish to be contacted by Veda Connect.
S
What is your current address?
Signature
Date
Postcode

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