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First Name:

Surname:

Address:

 State:

 Email:

Suburb:

Post Code:

Phone No:

 Lodge, Chapter, Preceptory Etc:       Name:                                                  Number:                                              State:            (Where the regalia will be used)                              

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Amount of Credit Required: $

Period of Credit Required:

Minimum of $50 per month 

 Signature of Applicant:

Date of Application:

Print Name:

Please ensure that you have read the requirements and conditions of credit. (See credit requirements and conditions page) and a signed copy is enclosed with this application of credit.

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Office Use Only

Amount Admin Fee cost 10%:

                                      $

Period of Credit Approved:

No of Months

 Amount of Credit Approved: $

Number of Months :

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Amount per Month:

Total Credit Approved: $

Start Date:

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Finish Date: