PERSONAL DETAILS:
Title *
—Please choose an option—MrMrsMiss
Full Names *
Last Name *
Initials
ID Number
Dependents
Sex
—Please choose an option—MaleFemale
Marital Status
—Please choose an option—Married ANCCOPSingleWidowedDivorced
Date Married
E-mail Address *
Tel: (H)
Tel: (W)
Cell Number *
Home Address
Period
Postal Address
Postal Code
Previous Address
Spouse Names
Spouse ID
Next of kin
Relationship
—Please choose an option—FatherMotherBrotherSisterUncleAuntGrandfatherGrandmotherCousinNephewNiece
Address of Kin
Contact Number
BOND DETAILS:
Bond Holder
Bank
—Please choose an option—ABSAAfrican BankCapitecFNBNedbankStandard BankWesbankOther Finance Institution
Outstanding Amount
Date Purchased
Registered Under
—Please choose an option—Own NameSpouse
Rental Amount
EMPLOYER DETAILS:
Employer
Occupation
Employer Address
Company Tel
No. of Years
Salary Date
Previous Employer
Spouse Employer
BANK DETAILS:
Name of Account Holder
Account Type
—Please choose an option—Credit CardCurrentSavingsTransmission
Bank Name
—Please choose an option—ABSAAfrican BankBidvest BankCapitecFNBNedbankStandard BankWesbankOther Bank
Branch Name
Branch Code
TRADE REFERENCE:
Branch
Account Number
Installments
Paid / Current / Settled / To Be Settled
ETHNIC GROUP:
Race
—Please choose an option—AfricanColouredCaucasianIndianOther
Language
—Please choose an option—EnglishAfrikaansZuluSothoOther
PERSONAL APPLICATION:
Salary Details: (Own) R
Salary Details: (Spouse) R
Basic Monthly (Excl. Car Allowance): (Own) R
Basic Monthly (Excl. Car Allowance): (Spouse) R
Car Allowance: (Own) R
Car Allowance: (Spouse) R
Total Salary (Basic + Car) (Own) R
Total Salary (Basic + Car) (Spouse) R
Monthly Commission (Own) R
Monthly Commission (Spouse) R
Net Take Home Pay (Own) R
Net Take Home Pay (Spouse) R
Income other than Salary/Wages ** (Own) R
Income other than Salary/Wages ** (Spouse) R
Sources of other Income ** (Own) R
Sources of other Income ** (Spouse) R
Total Monthly Household Income (Net Salary & Other) R
HOUSEHOLD EXPENSES PER MONTH:
Bond Repayment / Rent R
Rates, Water & Electricity R
Vehicle (Excluding those to be settled) R
Personal Loan Repayments R
Credit Card Repayments R
Furniture Account Repayments R
Clothing Account Repayments R
Overdraft Account Repayments R
Policy / Insurance repayments R
Telephone Account Repayments R
Transport cost Payments R
Food & Entertainment Budget R
Education Cost Payments R
Maintenance & Repair Payments R
Other Household Expenses R
Other Expenses & Payments R
Total Monthly Household Expenses R
Household Surplus / Disposable Income R
Are you currently Liable as:
—Please choose an option—SuretyGuarantorCo-Debtor
Specify Details
If you have signed surety or co-debtor, please indicate the full amount outstanding R
I confirm that:
A. I am not a minor. B. I have never been declared mentally unfit by a court. C. I am not subject to an administration order. D. I do not have any current application pending for debt restructuring or alleviation. E. I do not have any current debt re-arrangement in existence. F. I have not previously applied for a debt re-arrangement. G. I am not under sequestration. H. I do not have applications pending for credit, nor open quotations as envisaged in section 92 of the National Credit Act.
I. If any of the above is incorrect, give details:
DECLARATION BY CLIENT:
* I hereby grant the Credit Provider the right to communicate with me through any electronic/written media or verbally in order to make available to me, their product offering.
YESNO
* I hereby grant the Credit Provider the right to increase my Credit Limit once every year to accommodate any Value Added Products needed and requested by me.
* I hereby give consent to the Credit Provider to make enquiries about my credit record with any credit agency and to obtain whatever information on me they might require to process the application. I also give consent to the Credit Provider to share my payment behavior with any credit agency.
