Fields marked with * are required fields
I would like insurance for an extra $1 per week. This covers damage caused by fire, or theft of the appliance.
Contact Name* (as it appears on your passport, drivers licence or similar ID)
Gender* Male Female
Date of Birth*
Email*
Landline* (enter N/A if you do not have a landline)
Mobile*
If you are a student, enter your place of study here (e.g. University of Canterbury, ARA)
Street address* (Flat/Unit number, street number street name)
Suburb*
City* (sorry we do not service outside of Christchurch) Christchurch
Access or delivery instructions
Have you lived at the above address for more than 12 months? Yes No
Previous address If you have not lived at your current address for more than 12 months.)
* I have read and understood the terms and conditions of hire.
* I consent to a credit check being done as part of my application.
Security:
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