Pre-application check list



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PRE-APPLICATION CHECK LIST

Before completing a payment plan application, it is important to establish that the applicant can fulfil the pre-application criteria through the use of this quick check list.


If there is a tick in any of the shaded boxes then the application cannot proceed. This does not preclude the patient from treatment if their spouse/partner/parent becomes the applicant and can fulfil the criteria on a new check list.


PLEASE COMPLETE THIS CHECKLIST INDICATING YES OR NO WITH A TICK

YES

NO

1

Are you 18 years old or above?

If YES proceed to 2







2

Are you in permanent (min 16 hours per week) paid employment (excluding agency or child minding)?

If YES proceed to 6 and if NO proceed to 3







3

Are you retired and receiving a pension?

If YES proceed to 6 and if NO proceed to 4







4

Are you self employed?

If YES proceed to 6 and if NO proceed to 5









5

Does your spouse or partner fulfill one of the criteria in 2, 3 or 4?

If YES proceed to 6









6

Do you have your own or a joint Bank or Building Society current account for the direct debits?

If YES proceed to 8 and if NO proceed to 7








7

Does your spouse or partner have a bank or Building Society current account for the direct debits?

If YES proceed no further and speak to a member of the practice team








8

Have you lived in the UK for a minimum of 12 months and intend to continue your residency?

If YES proceed to 9








9

Do you have a debit card that is registered to your current address?

If YES proceed to 11 and if NO proceed to 10








10

Do you have a credit card that is registered to your current address?

If YES proceed to 11








11

Do you have one of the following in your name and registered at your current address:

Driving Licence / Utility Bill / Bank or Building Society Statement /Rent Book / Pension Book?







In order to process the application we will need to see the following:


  1. A debit or credit card for proof of signature

  2. One of the items in point 11 for proof of residency

  3. Your bank account details for Direct Debit purposes


PLAN APPLICATION FORM






plan details (FOR practice use only)

Treatment value:

£

Deposit:

£

Deposit paid by credit card



Plan value:

£

Goods

(Implants, Crowns etc.):






Please indicate application type:

0% IFC




7.9% -

IBC





BNPL -

IB





Term (months)




Monthly Payment

£




Section 1 – your personal details

(*IF YOU HAVE CHANGED YOUR SURNAME IN THE LAST 3 YEARS, GIVE FORMER SURNAME BELOW)

Title: Mr/Mrs/Miss/Dr




Date of birth:




Forename (FULL):




Home landline:




Middle Name:




Mobile number:




Surname:




Email address:




Former surname:*




Marital status:




Gender:




Number of children (under 18 years of age):




Hitachi Capital Consumer Finance may use my email address for communication purposes:

YES




NO







SECTION 2 (a)– YOUR CURRENT ADDRESS DETAILS

Time at Address:

Years




Months




Street:




House Number:




District:




House Name:




Town:




Flat Number:




Post Code:







SECTION 2 (B) – GIVE PREVIOUS ADDRESS IF LESS THAN 3 YEARS AT CURRENT ADDRESS

Time at Address:

Years




Months




Street:




House Number:




District:




House Name:




Town:




Flat Number:




Post Code:







SECTION 3 – YOUR ACCOMMODATION DETAILS

Are you:

The owner?




Living with parents?




An unfurnished tenant?




A furnished tenant?




I have a mortgage at my address:

YES




NO




I have held a mortgage for:

Years




Months







SECTION 4 – Delivery – is always no




SECTION 5 – PLEASE PRESENT ONE OF THE FOLLOWING PROOFS OF RESIDENCY (POR)

Driving licence




Licence Number

















































Utility Bill from last 3 months




Bank Statement from last 3 months




POR REF -date on document:




Official Document (Mortgage/Rent/Pension Book)




POR REF – reference number from document:






PLAN APPLICATION FORM cont’d







SECTION 6 (A) – YOUR EMPLOYMENT DETAILS

Are You:

Employed




Self-employed




Student




House Person




Retired




IF YOU ARE EMPLOYED OR SELF-EMPLOYED, ENTER DETAILS BELOW THEN GO TO SECTION 7

Work phone:




Length of time with current employer:

Years




Months




Occupation:




Employer:




Branch/Department:




Street:




Town/City:




County:




Your Gross Annual Income:

£

IF YOU ARE RETIRED, ENTER YOUR GROSS ANNUAL INCOME ABOVE THEN GO TO SECTION 7

IF YOU ARE A HOUSE PERSON GO TO SECTION 6 (B)




SECTION 6 (B) – IF YOU ARE A HOUSE PERSON,

ENTER YOUR SPOUSE OR PARTNER’S EMPLOYMENT DETAILS BELOW

Is He/She:

Employed




Self-employed




Retired (enter his/her income below )



Work phone:




Length of time with current employer:

Years




Months




Occupation:




Employer:




Branch/Department:




Street:




Town:




County:




His/Her Gross Annual Income:

£




SECTION 7 - BANK DETAILS FROM WHICH YOUR DIRECT DEBITS ARE TO BE TAKEN

Time at bank:

Years




Months




Account holder name:




Sort code:




Bank name:




Account number:




Branch:







SECTION 8 – FROM FOLLOWING LIST, TICK ALL CARDS YOU POSSESS

MasterCard




Diners




American Express




Visa




Debit Card




From long number on most used card, enter first 6 digits



















... and last 4 digits














**Section 9 is only required if the total amount of credit you are applying for is £9000+ after

any deposit has been made


SECTION 9 – MORTGAGE INFORMATION

Mortgage Balance:

£

Year of Purchase:




Initial Purchase Price:

£




USE OF YOUR INFORMATION AND CUSTOMER DECLARATION




What Hitachi will do when you apply:

Hitachi will search your record at credit reference and fraud prevention agencies and that of your 'financial associate' if you have one, i.e. a person with whom you have, or have had, joint personal financial arrangements such as joint accounts or have made joint credit applications. It may be your spouse or partner (not a business partner). Hitachi may also, in certain limited circumstances, check the record, including credit details, of other members of your family and, if you are a director or partner in a small business, they may also check on your business. If you tell Hitachi that you have a financial associate, they will search, link and record information about you both at credit reference agencies. You must be sure you have your financial associate's agreement to disclose their information. If you give Hitachi false or inaccurate information and they identify fraud, they will record this with fraud prevention agencies. Law enforcement agencies may access and use this information. Hitachi will use a scoring or other automated decision-making system to assess your application and to verify your identity.


How Hitachi will use your information you have provided

Whether or not Hitachi accept your application for credit, they may pass your personal information to members of their group of companies, or business partners, affiliates or other third parties, and to anyone who introduced you to them, who may use it to inform you by letter/telephone or by email about their products and services (which may not be financially related). If Hitachi do not accept your application for credit, they may pass your personal information to another lender or broker which may accept your application. The other lender or broker may carry out its own searches at credit reference and fraud prevention agencies. If you are accepted for credit and do not want to be contacted in this way please write to Hitachi Capital Consumer Finance, 2 Apex View, Leeds, West Yorkshire, LS11 9BH.


What Hitachi will also do when you have an agreement with them:

Hitachi will add to your record with the credit reference agencies details of your agreement with them, the payments you make under it, any default or failure to keep its terms and any change of name or address. Account information given to credit reference agencies remains on file for 6 years after the account is closed, whether settled by you or upon default.


What the credit reference agencies will do:

Whether or not this application proceeds, the credit reference agency will place a record of Hitachi’s search on your credit file. This record (but not Hitachi’s name) will be seen by other organisations when you apply for credit in the future. A large number of applications within a short period of time could affect your ability to obtain credit. Whether or not this application proceeds, the agencies will link your records and those of your financial associate(s), including any previous and subsequent names. These links will remain on your and their files until you or they tell the agency you are no longer financially linked and the agency accepts this. The agencies may supply Hitachi with credit information, such as previous applications, the conduct of accounts in your and your financial associate's name, any business accounts you have, fraud prevention information and public information such as County Court Judgments, bankruptcies and the Electoral Register.


How Hitachi and others use the agency information:

Some information held by the credit reference and fraud prevention agencies will be disclosed to Hitachi and other organisations to, for example:


• prevent fraud and money laundering, for example by checking details on applications for credit and credit-related or other facilities, proposals and claims for all types of insurance and job applications and employee records;

• recover debts that you owe and trace your whereabouts;

• manage credit accounts and other facilities;

• verify your identity;

• make decisions on credit, insurance and other facilities, about you, your financial associate(s), members of your household or your business; and

• carry out statistical analysis to help with decisions about credit and account management.


The information held by these agencies may also be used for other purposes for which you give your specific permission or, in very limited circumstances, when required by law or where permitted under the terms of the Data Protection Act 1998.
Hitachi and other organisations may access and use from other countries the information recorded by fraud prevention agencies.
Please write to 'PaybyFinance Team , Hitachi Capital (UK) PLC, 2 Apex View, Leeds, West Yorkshire, LS11 9BH', if you want details of those credit reference and fraud prevention agencies from which Hitachi obtain, and to which they pass, information about you. You have a legal right to these details. You have the right to receive a copy of the information Hitachi hold about you if you apply to them in writing. A fee will be payable.

By signing and dating this declaration I confirm that I have read and understood how Hitachi Capital (UK) PLC will use the information provided by me and also confirm that I have my financial associate’s agreement to disclose their information.

APPLICANT NAME: (PLEASE PRINT) ........................................................................................................................................................


APPLICANT SIGNATURE: ............................................................................................................... DATE:.............................................


PRACTICE SIGNATURE: ................................................................................................................. DATE:.............................................






Application 200212




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