*Please fill in all the fields


Please complete the form below

Agent Code: 2033

APPLICANT PERSONAL DETAILS

Full Names:
Surname:
Title: ID Number:
Language: Home Number:
Cell Number: Work Number:
Email:
Physical Address: Postal Address:
Postal Code: Postal Code:

Friend / relative 1:

Friend / Relative 2:

Name: Name:
Relation: Relation:
Cell Number: Cell Number:
Address: Address:
Postal Code: Postal Code:
PRE-QUALITY & MARKETING INFORMATION
Own or joint Bank Account with 2 month's salary deposited?: Yes  No
Are you under the following?
1) Administration Yes  No
2) Debt Councelling Yes  No
3) Debt Review Yes  No
4) Sequestration Yes  No
5) Liquidation Yes  No
May we include life Cover? Yes  No
Marital Status:
Purpose Of Loan:

EMPLOYMENT DETAILS

Company name:
Department/ section: Occupation:
Telephone: Email:
Gross salary: Net salary:
Period Employed: Pers Nr:
Payment Frequency: Weekly  Monthly
Salary Pay Date: Employment Status:
Physical Address: Postal Address:
Postal Code: Postal Code:

LIVING EXPENSES

Water / Electricity: Credit Card:
Maintenance: Telephone / Cell:
Children: Bond / Rent:
Groceries: Insurance Policy:
Transport / Fuel: Education / School:
Vehicle Expenses: Life Policy:
Vehicle Installments: Insurance Policy:
Clothing: Furniture:
Bank Loans: Other Loans:
    Other Expenses:

TOTAL EXPENSES :

BANKING DETAILS

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

VEHICLE DETAILS

Type of Vehicle: Car:| Sedan  SUV |Bakkie:  4X4  DC |Other Kombi  Bike
Make: Model:

TERMS AND CONDITIONS

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 its 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 information provided by me.


I further consent to the Credit Provider carryining out identity and fraud prevention tests. I also hereby authorize the Credit Provider to obtain a credit record from a credit bureau for purposes of an assessment prescribed by Section 81.


I Agree