Tinkable

130 High Street, Stourbridge, DY8 1DT tel 01384 373 734

Tinkable Finance my Treatment Plan. PRE-APPLICATION CHECK LIST

Before completing a payment plan application it is important to establish that the applicant can fulfil the preapplication criteria through the use of this quick check list. If there i a tick in any !f the ha"e" b!#e then the a$$licati!n cann!t $r!cee". Thi "!e n!t $recl%"e the $atient fr!m treatment if their $!% e&$artner&$arent bec!me the a$$licant an" can f%lfil the criteria !n a ne' check li t.

PLEASE CO PLE!E !"#S C"EC$L#S! #%&#CA!#%' (ES O( NO )#!" A !#C$

) * , . + 0 / 1 )2 )) Are you *+ years ol, or abo-e. #f (ES procee, to * Are you in permanent /min *0 hours per 1eek2 pai, employment /e3clu,ing agency or chil, min,ing2. #f (ES procee, to + an, if NO procee, to , Are you retire, an, recei-ing a pension. #f (ES procee, to + an, if NO procee, to Are you self employe,. #f (ES procee, to + an, if NO procee, to . &oes your spouse or partner fulfill one of the criteria in 45 6 or 7. #f (ES procee, to + &o you ha-e your o1n or a 8oint Bank or Buil,ing Society current account for the ,irect ,ebits. #f (ES procee, to / an, if NO procee, to 0 &oes your spouse or partner ha-e a bank or Buil,ing Society current account for the ,irect ,ebits. #f (ES procee, no further an, speak to a member of the practice team "a-e you li-e, in the 9$ for a minimum of *4 months an, inten, to continue your resi,ency. #f (ES procee, to 1 &o you ha-e a ,ebit car, that is registere, to your current a,,ress. #f (ES procee, to )) an, if NO procee, to )2 &o you ha-e a cre,it car, that is registere, to your current a,,ress. #f (ES procee, to )) &o you ha-e !ne of the follo1ing in your name an, registere, at your current a,,ress: &ri-ing Licence ; 9tility Bill ; Bank Statement ; (ent Book ; Pension Book.

(ES

NO

#n or,er to process the application 1e 1ill nee, to see the follo1ing: a2 A ,ebit or cre,it car, b2 One of the items in point ** c2 <our bank account ,etails

Application 47=***

Tinkable

130 High Street, Stourbridge, DY8 1DT tel 01384 373 734

PA(3ENT PLAN APPLICATION

PLAN 4ETAILS 5PRACTICE 6SE ONL(7 !reatment -alue: Plan type: !itle: @orename:/@9LL2 i,,le name: Surname: @ormer surname: 'en,er: !ime at A,,ress: "ouse %umber: @lat %umber: "ouse %ame: !ime at A,,ress: "ouse %ame: @lat %umber: "ouse %umber: Are you: !he o1ner. Li-ing 1ith parents. <E S %O <ears onths <ears onths > =? #@C &o1n-payment: A.B? #BC > B%PL -#B APPLICANT 4ETAILS &ate of birth: "ome phone: obile: Email: arital status: %umber of chil,ren /un,er *+ years of age2: APPLICANT A44RESS Street: &istrict: !o1n: Post Co,e: PRE8IO6S A44RESS 5IF LESS THAN , (EARS IN C6RRENT A44RESS7 Street: &istrict: !o1n: Post Co,e: T(PE OF ACCO33O4ATION An unfurnishe, tenant. # ha-e ha, a mortgage for: A furnishe, tenant. <ears onths Plan -alue: > !erm /months2:

# ha-e a mortgage at my a,,ress:

E3PLO(3ENT 4ETAILS 5PLEASE CO3PLETE F6LL(7 Status: Occupation: )ork phone: Employer: Street: Enter 'ross Annual Salary: &ri-ing licence 9tility Bill &ebit Licence %umber Official &ocument Bank guarantee Bank Statement asterCar, &iners POR Ref> American E3press ... an, last - ,igits Account hol,er name: Bank name: Branch: Disa CAR4S APPLICANT POSSESSES @rom long number on m! t % e" car" 5 enter first + ,igits !ime at bank: Sort co,e: Account number: <ears onths = PROOF OF RESI4ENC( 5POR7 !o1n: Employe, Self-employe, (etire, "ousepersonC $!% e&$artner< Stu,entC Enter y!%r em$l!yment "etail bel!' !r if y!% ticke" a 9 cate:!ry; enter y!%r em$l!yment "etail

Spouse or partner employment status: Length of time 1ith this employer: Branch;&epartment: County: <ears onths

?ANK 4ETAILS FRO3 @HICH 4IRECT 4E?ITS ARE TO ?E TAKEN

A44ITIONAL APPLICATION 4ETAILS

Application 47=***

Tinkable

130 High Street, Stourbridge, DY8 1DT tel 01384 373 734

The e a""iti!nal "etail are !nly reA%ire" 'hen the am!%nt t! be f%n"e" i =1222B after any "!'n$ayment an"&!r "e$! it ha been "e"%cte" fr!m the !Cerall c! t !f treatment

ACCO33O4ATION
ortgage balance <ear of purchase #nitial purchase price > >

3!re !n ne#t Pa:eDDDD.

6SE OF (O6R INFOR3ATION AN4 C6STO3ER 4ECLARATION

@hat Hitachi 'ill "! 'hen y!% a$$ly> Application 47=***

Tinkable

130 High Street, Stourbridge, DY8 1DT tel 01384 373 734

"itachi 1ill search your recor, at cre,it reference an, frau, pre-ention agencies an, that of your Efinancial associateE if you ha-e one5 i.e. a person 1ith 1hom you ha-e5 or ha-e ha,5 8oint personal financial arrangements such as 8oint accounts or ha-e ma,e 8oint cre,it applications. #t may be your spouse or partner /not a business partner2. "itachi may also5 in certain limite, circumstances5 check the recor,5 inclu,ing cre,it ,etails5 of other members of your family an,5 if you are a ,irector or partner in a small business5 1e may also check on your business. #f you tell "itachi that you ha-e a financial associate5 they 1ill search5 link an, recor, information about you both at cre,it reference agencies. <ou must be sure you ha-e your financial associateEs agreement to ,isclose their information. #f you gi-e "itachi false or inaccurate information an, they i,entify frau,5 they 1ill recor, this 1ith frau, pre-ention agencies. La1 enforcement agencies may access an, use this information. "itachi 1ill use a scoring or other automate, ,ecision-making system to assess your application an, to -erify your i,entity. H!' Hitachi 'ill % e y!%r inf!rmati!n y!% haCe $r!Ci"e" )hether or not "itachi accept your application for cre,it5 they may pass your personal information to members of their group of companies5 or business partners5 affiliates or other thir, parties5 an, to anyone 1ho intro,uce, you to them5 1ho may use it to inform you by letter;telephone or by email about their pro,ucts an, ser-ices /1hich may not be financially relate,2. #f "itachi ,o not accept your application for cre,it5 they may pass your personal information to another len,er or broker 1hich may accept your application. !he other len,er or broker may carry out its o1n searches at cre,it reference an, frau, pre-ention agencies. #f you are accepte, for cre,it an, ,o not 1ant to be contacte, in this 1ay please 1rite to "itachi Capital Consumer @inance5 4 Ape3 Die15 Lee,s5 )est <orkshire5 LS** BB". @hat Hitachi 'ill al ! "! 'hen y!% haCe an a:reement 'ith them> "itachi 1ill a,, to your recor, 1ith the cre,it reference agencies ,etails of your agreement 1ith them5 the payments you make un,er it5 any ,efault or failure to keep its terms an, any change of name or a,,ress. Account information gi-en to cre,it reference agencies remains on file for 0 years after the account is close,5 1hether settle, by you or upon ,efault. @hat the cre"it reference a:encie 'ill "!> )hether or not this application procee,s5 the cre,it reference agency 1ill place a recor, of "itachiFs search on your cre,it file. !his recor, /but not "itachiFs name2 1ill be seen by other organisations 1hen you apply for cre,it in the future. A large number of applications 1ithin a short perio, of time coul, affect your ability to obtain cre,it. )hether or not this application procee,s5 the agencies 1ill link your recor,s an, those of your financial associate/s25 inclu,ing any pre-ious an, subsequent names. !hese links 1ill remain on your an, their files until you or they tell the agency you are no longer financially linke, an, the agency accepts this. !he agencies may supply "itachi 1ith cre,it information5 such as pre-ious applications5 the con,uct of accounts in your an, your financial associateEs name5 any business accounts you ha-e5 frau, pre-ention information an, public information such as County Court Gu,gments5 bankruptcies an, the Electoral (egister. H!' Hitachi an" !ther % e the a:ency inf!rmati!n> Some information hel, by the cre,it reference an, frau, pre-ention agencies 1ill be ,isclose, to "itachi an, other organisations to5 for e3ample: H pre-ent frau, an, money laun,ering5 for e3ample by checking ,etails on applications for cre,it an, cre,it-relate, or other facilities5 proposals an, claims for all types of insurance an, 8ob applications an, employee recor,sI H reco-er ,ebts that you o1e an, trace your 1hereaboutsI H manage cre,it accounts an, other facilitiesI H -erify your i,entityI H make ,ecisions on cre,it5 insurance an, other facilities5 about you5 your financial associate/s25 members of your househol, or your businessI an, H carry out statistical analysis to help 1ith ,ecisions about cre,it an, account management. !he information hel, by these agencies may also be use, for other purposes for 1hich you gi-e your specific permission or5 in -ery limite, circumstances5 1hen require, by la1 or 1here permitte, un,er the terms of the &ata Protection Act *BB+. "itachi an, other organisations may access an, use from other countries the information recor,e, by frau, pre-ention agencies. Plea e 'rite t! EPaybyFinance Team ; Hitachi Ca$ital 56K7 PLC; * A$e# 8ie'; Lee" ; @e t (!rk hire; LS)) 1?HE; if y!% 'ant "etail !f th! e cre"it reference an" fra%" $reCenti!n a:encie fr!m 'hich Hitachi !btain; an" t! 'hich they $a ; inf!rmati!n ab!%t y!%. (!% haCe a le:al ri:ht t! the e "etail . (!% haCe the ri:ht t! receiCe a c!$y !f the inf!rmati!n Hitachi h!l" ab!%t y!% if y!% a$$ly t! them in 'ritin:. A fee 'ill be $ayable. ?y i:nin: an" "atin: thi "eclarati!n I c!nfirm that I haCe rea" an" %n"er t!!" h!' Hitachi Ca$ital 56K7 PLC 'ill % e the inf!rmati!n $r!Ci"e" by me an" al ! c!nfirm that I haCe my financial a !ciate< a:reement t! "i cl! e their inf!rmati!n.

APPL#CA%! %A E: /PLEASE P(#%! ....................................................................................................................................................

APPL#CA%! S#'%A!9(E: ...............................................................................................................&A!E:...........................................

P(AC!#CE S#'%A!9(E: .......................................................................................................................&A!E:.............................................

Application 47=***