Initial Global Care Dubbo NILS Loan Enquiry Form
Enquiry Date: 04/05/2024 03:25:22
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Consent to Statistical Data Collection
Yes
No
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Have you previously had, or do you currently have a NILS Loan: Yes
No
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First Name:
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Last Name
*
Date of birth:
(dd/mm/yyyy)
*
Address:
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Town:
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Post Code:
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Phone Number/s (H):
(M):
Email Address:
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Gender:
Male
Female
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Aboriginal/Torres Strait Islander?
YES
NO
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Do you want your information letter by :
Email or
Hand Delivered
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Where were you Born?
Australia
Other
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Your Age:
0 – 17
18 – 24
25 – 34
35 – 44
45 – 54
55 – 64
65+
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Number of Adults in house
Number of children in house and age group:
Number
Ages:
0 – 5
6-10
11-15
16+
(more than one box may be selected)
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Who lives in your House?
Adults – No Children
Adults – Children
Couple -Children (married
or defacto
relationship)
Couple –No Children (married
or defacto
relationship)
Single – Children
Single – No Children
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Do you live in :
Public Rent – Dept of Housing Other
Private Rent
Own House / Mortgage
Living with relatives
Caravan park / mobile home
Transitional housing
Other
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Centrelink Income:
Abstudy
Newstart
Age Pension
None
Austudy
Parenting Payment - Single
Carers Payment
Parenting Payment - Partner
Disability Support
Sickness Benefit
Family Tax Benefit A
Special Benefit
Family Tax Benefit B
Other Govt Allowance
*
Other Income:
None
Non wages income
Other
Wages
*
How did you hear about us?
Family / Friend
Pamphlet
Government Agency
Previous Borrower
Inhouse
TV / Radio
Internet
Unknown
Newspaper / Magazine
Other
Non government organisation
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How long have you lived at you current address?
0 – 3months
3 – 6months
6 – 12months
1 – 2years
2years +
If less than
6
months - what was previous address:
Do you have a :
Health Care Card
Pension Card
Loan eligibility will be assessed on an individual basis
*
Item Required
Household Appliances
Household Furniture
Technology
Health
Education
Outdoor Equipment
Car related expenses
Repairs
Economic Participation
Other
Extra Information:
Office Use Only
Enquiry made by:
From:
Dubbo
Parkes
Narromine
Wilcannia
Trangie
Lightning Ridge
Walgett
Collarenebri
Bourke
Other
