Name *

First Name

Last Name

Phone

(###)

###

####

Date of Birth

MM

DD

YYYY

Acknowledgement & Authorisation *

Acknowledgement & Authorisation I understand that Mode Rideshare Ltd is collecting information about me to determine whether to open an account in my name. In assessing whether to open an account in my name, information collected and held about me may be exchanged with organisations, including ride-sharing and other related companies, credit providers and government departments. Any information collected may also be used by Mode Rideshare Ltd from time to time for credit assessment and control purposes, for sending me promotional and other materials about the products and services it supplies, and generally to do business with me. The information exchanged and held may include, but is not limited to Driver checks, Fines Checks, Credit Checks, Police Checks and Insurance Checks. Under the Privacy Act, individuals have rights of access to and correction of their personal information. I may also request the full details of every organisation or person to whom Mode Rideshare Ltd has disclosed information about me.

I have read, understand and agree to the terms and conditions above