Start your Car Subscription Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Date of birth * MM DD YYYY Licence number * Licence Expiry date * MM DD YYYY State/Country * Licence Type * Probationary Licence Full Licence Intternational Licence Passport Number If you hold an international licence you must also include your passport details. Passport Expiry Date MM DD YYYY Employer Name * Job Title * Employment Length * Employer Phone number * (###) ### #### Employer Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Employer Email * Reference Name * First Name Last Name Car * 5 seater 7 seater 8 seater Length of Subscription * Before your contract ends you must come back in to sign a new contract if you would like to extend your subscription. 6 Months 12 Months Additional Driver * You can add an Addtional Driver from the same residence for an extra $10 per week. Yes No Additional driver's Name First Name Last Name Additional driver's Phone (###) ### #### Additional driver's Email Additional driver's Licence Number Additional driver's Licence State/Country Additional driver's licence Expiry date MM DD YYYY Additional driver's Date of birth MM DD YYYY Have you or any nominated drivers had a licence cancelled, disqualified or suspended in the last 3 years? * Yes No Have you or any nominated drivers had any criminal, drink or drug driving convictions in the last 5 years? * Yes No Have you or any nominated drivers made two or more motor insurance claims in the last 3 years? * Yes No Exalt Auto Group Car Subscription uses Pay Advantage Direct Debit as our preferred payment method. * By ticking this box for this Direct Debit Request, you request and authorise us to arrange for funds to be debited from your account according to the agreement which we have with you, using a third party which is Pay Advantage. The amounts drawn will be as due under the agreement or any agreed variations to it thereafter or any greater amount which you, either or you, or a third party instruct us to draw, provided such instruction is given in the manner specified in the operating authority held by us in connection with your account. Yes I confirm that the above information is correct and authorise Exalt Auto Group Vic Pty Ltd to collect, use and disclose information about me for the purpose of evaluating and assessing my application for an Exalt Auto Group car subscription. I authoise any third person to provide information about me for that purpose, or any law enforcement requests. * Yes I understand that providing false information could void my application and insurance cover * Yes I acknowledge and Agree to the Terms & Conditions * Yes Thank you!
