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Page 1
Co-pilot Application Form
Upload Your Final Quote
BROKER DETAILS
First Name
Last Name
Email
Phone
APPLICANT PERSONAL DETAILS
Title
Please select...
Mr.
Mrs.
Ms.
Miss
Dr.
Prof.
First Name
Middle Name
Last Name
Date of Birth
Marital Status
Please select...
Married
Single
Defacto
Separated
Number of Dependents
Driver's Licence Number
Driver's Licence Card Number
Expiry
Upload a photo of the front of your driver's licence
Upload a photo of the back of your driver's licence
Medicare Card Number
Phone
Email Address
Secondary Email Address
Residential Address
Address
Suburb
State
Please select...
Victoria
New South Wales
Australian Capital Territory
South Australia
Western Australia
Queensland
Northern Territory
Tasmania
Postcode
Status
Please select...
Own
Rent
Boarding
Employer Supplied
Monthly Payment
Time at Address: Years
Months
Mortgagor or Landlord Name
Landlord Contact Number
Postal Address Same With Residential Address?
Yes
No
Postal Address
Address
Suburb
State
Please select...
Victoria
New South Wales
Australian Capital Territory
South Australia
Western Australia
Queensland
Northern Territory
Tasmania
Postcode
PREVIOUS ADDRESS
Address
Suburb
State
Please select...
Victoria
New South Wales
Australian Capital Territory
South Australia
Western Australia
Queensland
Northern Territory
Tasmania
Postcode
Status
Please select...
Own
Rent
Boarding
Employer Supplied
Monthly Payment
Time at Address: Years
Months
Mortgagor or Landlord Name
Landlord Contact Number
APPLICANT EMPLOYMENT DETAILS
Current Employer
Job Title
Employer Address
Time with Employer: Years
Months
Contact Person
Contact Person's Phone
Contact Person's Email
Employment Details
Please select...
Australian Citizen
Permanent Resident
Visa Holder
Visa Type
Visa Image
PREVIOUS EMPLOYMENT DETAILS
Previous Employer
Job Title
Employer Address
Time with Employer: Years
Months
Contact Person
Contact Person's Phone
Contact Person's Email
Page 2
INCOME STATEMENT
Take-home Pay
Weekly
Fortnightly
Monthly
Applicant income
Annual
Take-home Pay (Weekly)
Take-home Pay (Fortnightly)
Take-home Pay (Monthly)
Upload your most recent payslip
Upload your second most recent payslip
Spousal income
Annual
Take-home Pay (Weekly)
Take-home Pay (Fortnightly)
Take-home Pay (Monthly)
Upload your spouse's most recent payslip or proof of income documentation
Upload your spouse's second most recent payslip or proof of income documentation
Additional income
Annual
Take-home Pay (Weekly)
Take-home Pay (Fortnightly)
Take-home Pay (Monthly)
Investment/
Rental income
Annual
Take-home Pay (Weekly)
Take-home Pay (Fortnightly)
Take-home Pay (Monthly)
Government
Benefit Income
Annual
Take-home Pay (Weekly)
Take-home Pay (Fortnightly)
Take-home Pay (Monthly)
Total Annual
Total Take-home Pay
ADDITIONAL INFORMATION AND CREDIT INFRINGEMENTS (if applicable)
Adverse Credit History - note any that apply
Defaults
Bankruptcies and/or debt agreements
LIVING EXPENSES STATEMENT (MONTHLY)
Groceries
Utilities & Rates
Clothing & Personal
Insurances
Transport
Entertainment
Phone & Internet
Medical & Health
Education & Childcare
Other
Please specify
Total
Other Notes
DECLARATION
I certify that the above details are true and correct, as at the date below and that I have listed all known expenses incurred on a monthly basis
Page 3
ASSETS AND LIABILITIES
Primary Residence
Value
Balance
Monthly Commitment
Bank Lender
Investment Properties
Please select the number of Investment Properties
Please select...
0
1
2
Value
Balance
Monthly Commitment
Bank Lender
Value
Balance
Monthly Commitment
Bank Lender
Motor Vehicle/s
Please select the number of Motor Vehicles
Please select...
0
1
2
Value
Balance
Monthly Commitment
Bank Lender
Asset Type
Asset Name
Value
Balance
Monthly Commitment
Bank Lender
Asset Type
Asset Name
Other Equipment/s
Value
Balance
Monthly Commitment
Bank Lender
Asset Type
Asset Name
Personal Loan/s
Please select the number of Personal Loans
Please select...
0
1
2
Value
Balance
Monthly Commitment
Bank Lender
Value
Balance
Monthly Commitment
Bank Lender
Credit Card/s
Please select the number of Credit Cards
Please select...
0
1
2
Value (Limit)
Balance
Monthly Commitment
Bank Lender
Value (Limit)
Balance
Monthly Commitment
Bank Lender
Home Contents / Personal
Value
Cash at hand / savings
Value
Shares / Investments
Value
Superannuation
Please select the number of Superannuation Funds
Please select...
1
2
Value
Value
Summary
Total Value
Total Balance
Total Monthly Commitment
DECLARATION
I have read and understood the particulars that have been completed in this declaration and state that those particulars are true, complete and not misleading, and have been made to Positive Salary Packaging to enable it to assess my application.
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