*Please fill in all the fields

Please complete the form below

Please complete this form as accurately as possible when applying for a Personal Loan.

This will allow us to process your request much faster.

Agent Code :


Loan Details

Loan Amount:
Loan Term:
Instalment (Optional):

Applicant Personal Details

Email Address: Title:
Language: Surname:
Full Names: ID Num:
Cell Number: Home Number:

Physical Address:

Postal Address:

Address: Address:
Postal Code: Postal Code:
City: City:
Friend/Relative: Friend/Relative (2):
Name: Name:
Cell: Cell:
Address : Address :

Pre-Quality & Marketing Information

Own or joint Bank Account with 2 months
Salary deposited?
Yes No
Are you under the following? 1)Administration 2)Debt Councelling 3)Debt Review 4)Sequestration 5)Liquidation Yes No
Can we include Credit Life Cover? Yes No
Marital Status:
Loan Purpose :

Employment Details

Gross Salary Net Salary
Company Name: Period Employed:
Department: Payment Frequency:
Salary Pay Date: Employment Status:

Living Expenses:

Rates / Water & Electricity: Cell / Tel / Airtime:
ex or children
Bond / Rental:
Groceries: Education / School / Daycare:
Transport / Fuel / Taxi: Life Insurance / Investments / Insurance:
Credit Card: Car Installments:
Personal Loans / Micro Loans: Furniture / Other HP:
Clothing: Other Expenses:

Banking Details

Bank Name:
Account Holder:
Account Number:
Account Type:
Branch Code:
Branch Name:

Please Read Terms and Conditiions

I declare that the above information is true and correct. This application is subject to final approval and may be accepted or rejected by the Credit Provider at its sole discretion, subject to it's final credit assessment process.

I consent to the Credit Provider making enquiries about my credit record with any credit reference agency or with any party as per the information provided by me. I further consent to the Credit Provider carrying out identity and fraud prevention tests.

I also hereby authorize the Credit Provider to obtain a credit report from a credit bureau for purposes of an assessment prescribed by Section 81.

I Agree