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40 Connaught Street, Application #

Blockhouse Bay, Auckland


[PH] 0800-028512
Email: info@rentronics.co.nz ____________________
RENT-FIX ORDER FORM
Date: Team Leader: Salesperson: Sales Type:

CUSTOMER DETAILS:
Full Name
(Name in full)
Address
City Postcode
Telephone Mobile
Email

Are you Working? Yes No Date of Birth / /


ID sighted ID#
Passport Drivers Expiry Date / /
(please circle)
Other (please specify) Over 18 Years Yes No
ALTERNATE CONTACTS: (Can be your Father, Mother, Son, Daughter or a Friend)
Name Name
Address Address
Contact number Contact number
Relationship to you Relationship to you

PRODUCT AND CREDIT DETAILS:


Product Description Weekly Payment Fortnightly Payment

PAYMENT PLAN DETAILS


NEW CUSTOMER [ ] OR EXISTING CUSTOMER [ ]

PAYMENT METHOD & FREQUENCY


DAY YOU GET PAID [ ] DAY PAYMENT DEBITED [ ] PAYMENT START DATE / /
FREQUENCY OF PAYMENT $ PAID WEEKLY $ PAID FORTNIGHTLY

DELIVERY DETAILS
MINIMUM PAYMENTS [ ] TOTAL AMOUNT $ EXPECTED DELIVERY DATE / /

RENT-FIX TERM
START DATE / / END DATE / / ] TOTAL PAYMENTS [ ]

DECLARATION
I ______________________________________________ agree to RENT-PURCHASE THE GOOD(s) above on the terms and conditions
in this RENT-FIX CONTRACT and in the general terms and conditions and
_______________________________________________ confirm to the best of my knowledge that all the above information is true
(PRINT FULL NAME CLEARLY) and correct.

DATE / / SIGNED ________________________________________________

NOTICE TO CUSTOMER: RIGHT OF CANCELLATION


Summary of your right to cancel under section 36F(1) of the Fair Trading Summary of your right to cancel under Section 36M(1) of the Fair Trading Act
Act 1986. The Fair Trading Act 1986 gives you a right to cancel this Rent-Fix 1986:
Contract: at any time before you take possession of the Goods; and in any Within 5 working days after the date you receive a copy of this Rent-Fix Contract; or
way (including oral or written) that shows your intention to cancel or if we fail to make disclosure under section 36L of the Act, at any time.
withdraw from this Rent-Fix Contract.
This statement only contains a summary of your rights and obligations in connection with your right to cancel. If there is anything about your rights or obligations under the Fair
Trading Act 1986 that you do not understand, if there is a dispute about your rights, or if you think that we are being unreasonable in any way, you should seek legal advice
immediately.