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	* - Fields Are Required
Club/Hotel Name*
ABN
Street Address*
State or Territory*	ACT NSW NT QLD SA TAS VIC WA
Postcode*
Contact Name*
Business Phone*
Mobile*
Fax
Email*
Current Bankers*
No. of Poker Machines Held*
Equipment Information
Goods to be purchased*	New Used
Description of Goods*
Amount to be financed*
Term*	24 36 45 60 Months
HP/Lease/Rental/Novated Lease	HP Lease Rental Novated Lease
Balloon/residual	% $
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