Residential Application Form

Residential Application Form
For your application to be processed you must answer all questions
(Including the reverse side)
PRDnationwide Perez Real Estate - Maroubra
This is a free service that connects all your utilities
Phone Number:
Fax Number:
Email Address:
Direct Connect will make all reasonable efforts to contact you within 24 hours of the nearest working
day on receipt of this Application to confirm the information on this Application and explain the details
of the services offered. Direct Connect is a utility one stop connection service.
235 Maroubra Road, Maroubra NSW 2035
(02) 8347 0700
(02) 8347 0555
[email protected]
Once we have received this application we will call you to confirm your details.
Please tick utilities as required
Property Manager
1. What is the address of the property you would like to rent?
2. Lease commencement date?
3. Lease term?
4. How many tenants will occupy the property?
Ages of
5. Please give us your details
SurnameGiven Name/s
Date of Birth
Driver’s licence number
Driver’s licence expiry date
Driver’s licence state
Passport no.
Passport country
Pension no. (if applicable)
Pension type (if applicable)
6. Please provide your contact details
Home phone no.
Mobile phone no.
Work phone no.
Pay TV
DECLARATION AND EXECUTION: By signing this application, I/we: consent to Direct Connect
arranging for the connection and disconnection of the nominated utility services and to providing
information contained in this application to utility providers for this purpose; acknowledge having been
provided with terms and Conditions of Supply of Direct Connect and having read and understood
them together with the Privacy Collection Notice set out below; declare that all the information
contained in this application is true and correct and given of their own free will; expressly authorise
Direct Connect to provide any information disclosed in this Application to a supplier or potential
supplier of the Services in accordance with the Privacy Collection Notice and to obtain any information
necessary in relation to the Services; expressly authorise Direct Connect to provide any information
disclosed in this Application to an information provider for the purpose of that information provider
disclosing it to a supplier or potential supplier of the Services in accordance with the Privacy
Collection Notice and to obtain any information necessary in relation to the Services; consent to
Direct Connect contacting me by telephone or by SMS in relation to the marketing or promotion of all
of the services listed under the heading “Utility Connections” above even if we/I have not applied for
the connection of those services in this application. This consent will continue [for a period of 1 year
from the date of our/my execution of this application/until [28] days after we/I disconnect the last of
the services in respect of which this application is made]; acknowledge that this consent will permit
Direct Connect to contact us/me even if the telephone numbers listed on this application form are
listed on the Do Not Call Register; understand that under the requirements of the Privacy Act 1988,
Direct Connect will ensure that all personal information obtained about me/us will be appropriately
collected, used, disclosed and transferred and will be stored safely and protected against loss,
unauthorised access, use, modification or disclosure and any other misuse; authorise the obtaining
of a National Metering Identifier (NMI) for my residential address to obtain supply details; consent
to Direct Connect disclosing my/our details to utility providers (including my/our NMI and telephone
number); declare and undertake to be solely responsible for all amounts payable in relation to the
connections and/or supply of the Services and hereby indemnify Direct Connect and its officers,
servants and agents and hold them indemnified against any charges whatsoever in respect of the
Services; acknowledge that, to the extent permitted by law, Direct Connect shall not be liable for any
loss or damage (including consequential loss and loss of profits) to me/us or any other person or
any property as a result of the provision of the services or any act or omission by the utility provider
or for any loss caused by or in connection with any delay in connection, disconnection or provision
of, or failure to connect or disconnect or provide, the nominated utilities; acknowledge that whilst
Direct Connect is a free service I/we may be required to pay standard connection fees or deposits
required by various utility providers; acknowledge that the Services will be provided according to
the applicable regulations and that the time frames and terms and conditions of the nominated
utility providers bind me/us and that after hours connections may incur additional service fees from
utility providers; acknowledge that the real estate agent listed on this application form may receive
a benefit from Direct Connect in connection with the provision of the service being provided to
me/us by Direct Connect; and acknowledge the entitlement of Direct Connect and its associates,
agents and contractors, to receive a fee or remuneration from the utility provider and that such fee
or remuneration will not be refunded to me as a rebate in connection with the provision of the utility
connection services.By signing this application form, I warrant that I am authorised to make this
application and to provide the consents, acknowledgements, authorisations and other undertakings
set out in this application form on behalf of all applicants listed in this application form.
PO Box 1519, Box Hill, Victoria 3128. P: 1300 664 715 F:1300 664 185.
I hereby offer to rent the property from the owner under a lease to be prepared by the Agent. Should
this application be accepted by the landlord I agree to enter Into a Residential Tenancy Agreement.
I acknowledge that this application is subject to the approval of the owner/landlord. I declare that all
information contained in this application (including the reverse side) is true and correct and given of
my own free will. I declare that I have Inspected the premises and am not bankrupt.
I authorise the Agent to obtain personal Information from:
(a) The owner or the Agent of my current or previous residence;
(b) My personal referees and employer/s;
(c) Any record listing or database of defaults by tenants such as NTD, TICA or TRA for the
purpose of checking your tenancy history;
I am aware that I may access my personal information by contacting •
NTD: 1300 563 826
TICA: 1902 220 346
TRA: (02) 9363 9244
If I default under a rental agreement, I agree that the Agent may disclose details of any such
default to a tenancy default database, and to agents/landlords of properties I may apply for in the
Fax no.
Email address
7. What is your current address?
8. How did you find out about this property?
The Internet
Local Paper
Office Window
Sign Board at property
Other (specify)
Application sent to
Direct Connect (if Required)
I am aware that the Agent will use and disclose my personal information in order to:
(a) communicate with the owner and select a tenant
(b) prepare lease/tenancy documents
(c) allow tradespeople or equivalent organisations to contact me
(d) lodge/claim/transfer to/from a Bond Authority
(e) refer to Tribunals/Courts & Statutory Authorities (where applicable)
(f) refer to collection agents/lawyers (where applicable)
(g) complete a credit check with NTD (National Tenancies Database)
(h) transfer water account details into my name
I am aware that if information is not provided or I do not consent to the uses to which personal
information is put, the Agent cannot provide me with the lease/tenancy of the premises.
9. How long have you lived at your current address?
10. Why are you leaving this address?
Relationship to you
11. Landlord/Agent details of this property (if applicable)
Name of landlord or agent
Landlord/agent’s phone no.
17. Please provide a contact in case of emergency
Given name/s
Weekly Rent Paid
Phone no.
18. Please provide 2 personal references (not related to you)
Given name/s
1. Surname
Relationship to you
Phone no.
2. Surname
Given name/s
Relationship to you
Phone no.
12. What was your previous residential address?
13. How long did you live at this address?
14. Landlord/Agent details of this property (if applicable)
Name of landlord or agent
Landlord/agent’s phone no.
Weekly Rent Paid
Was bond refunded in full?
If not why not?
19. Car Registration
20. Please provide details of any pets
Council registration / number
Property Rental
15. Please provide your employment details
What is your occupation?
per week
First payment of rent in advance
Rental Bond (4 weeks rent):
Sub Total
Employer’s name (inc. accountant if self employed or institution if student)
Less: Holding deposit (see below)
What is the nature of your employment?
Amount payable on signing tenancy agreement
(bank cheque or money order only)
Employer’s address
Phone no.
Length of employment
Net Income
16. Please provide your previous employment details
Employer’s name
Contact name
Phone no.
Length of employment
Net Income
The holding fee can only be accepted after the application for tenancy is approved.
Contact name
The holding fee (not exceeding 1 week’s rent) of .............................. keeps the
premises off the market for the prospective tenant for 7 days (or longer by
In consideration of the above holding fee paid by the prospective tenant, the
landlord’s agent acknowledges that:
(i) The application for tenancy has been approved by the landlord; and
(ii) The premises will not be let during the above period, pending the making of a
residential tenancy agreement;
(iii) If the prospective tenant(s) decide not to enter into such an agreement, the
landlord may retain the whole fee;
(iv) If a residential tenancy agreement is entered into, the holding fee is to be paid
towards rent for the residential premises concerned.
(v) The whole of the fee will be refunded to the prospective tenant if:
(a) the entering into of the residential tenancy agreement is conditional on the
landlord carrying out repairs or other work and the landlord does not carry out the
repairs or other work during the specified period
(b) the landlord/landlord’s agent have failed to disclose a material fact(s) or made
misrepresentation(s) before entering into the residential tenancy agreement.
Signature of Landlords agent
Signature of Applicant