Fund My Dental $10k Application Form

Fund My Dental $10k

Let’s get started!Your application will only take a few minutes
Fill in your details below and a member of our Fund My Dental financing team will contact you to finalise the application process.
Loan Amount
Purpose
Name of Dental Clinic you wish to use funds at:
Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Number of dependants
Gender
Marital Status
Email
example@example.com
Mobile Number
Drivers Licence Number
Medicare Number
Medicare Card (Line Number)
(the number that appears on the right of your Medicare card if there are multiple names listed)
Employment Status
Occupation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years at Address
Please provide the following information to help speed up the application process
Last 3 months of payslips (showing your main income and any additional income)

Cancelof
Last 3 months of bank statements (for all bank accounts, including any joint accounts)

Cancelof
Assets (what you own)
Liabilities (what you owe, including credit cards and any BNPL loans)
Credit Reporting Policy:

I have read and agree to Fund My Dental's Credit Reporting Policy. Fund My Dental's Credit Reporting Policy can be obtained here or by calling 1800 356 779
Privacy Policy:

I have read and agree to Fund My Dental's Privacy Policy. Fund My Dental's Privacy Policy can be obtained here or by calling 1800 356 779
Signature
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