Online Your First Name (required) Your Surname (required) Your ID No (required) Date of birth (required) Language Marital Status How long How married Dependants Ages Home address Tel(H) Your Email (required) How long How long Previous address How long Driver's licence Yes/No Code How long Employer Branch Dept. Occupation How long Salary (gross) R (nett) R Tel(w) Cel no Previous employer How long Spouse first name ID no Employer Branch How long Dept. Occupation Email (required) Salary (gross) R (nett) R Tel(w) Cel no Other income Source Amount R Any previous financial problems Reasons HAVE YOU GOT SOMEONE WHO WILL SIGN SURETY FOR YOU? Yes/No Name Relationship Name and address of nearest relative not living with you 1. Relationship Tel(h) Tel(w) Cel no 2. Relationship Tel(h) Tel(w) Cel no Are you currently liable as surety or co-debtor? Yes/No Specify details Amount owing R Bankers Branch A/c type A/c No Fixed deposit:Yes/No Amount R Do you own or rent a house? Date purchased Purchase price R Bond R Current value R Bond holder Who's name TRADE REFERENCES 1. Company Branch When bought A/c no Paid/current 2. Company Branch When bought A/c no Paid/current 3. Company Branch When bought A/c no Paid/current 4. Company Branch When bought A/c no Paid/current Bond payment/rent R Rates, water and electricity R Clothing accounts R Furniture accounts R Telephone payments R Education costs R Food and entertainment R Maintenance R Personal loans R Insurance policies R Credit card payments R Vehicle instalments R Transport cost R Overdraft payments R Other R GROSS TOTAL R Household income details: Car allowance: R Other income R Total nett income (all combined) R Disposable income R I COMFIRM THE FOLLOWING: 1. I HAVE NEVER BEEN DECLARED MENTALLY UNFIT BY A COURT. 2. I AM NOT SUBJECTED TO AN ADMINISTRATION ORDER OR UNDER SEQUESTRATION. 3. I DO NOT HAVE ANY CURRENT APPLICATION PENDING FOR DEBT RESTRUCTURING OR ALLEVIATION. 4. I DO NOT HAVE ANY CURRENT DEBT RE-ARRANGEMENT. 5. I HAVE NOT PREVIOUSLY APPLIED FOR DEBT RE-ARRANGEMENT. 6. I DO NOT HAVE APPLICATIONS PENDING FOR CREDIT, NOR OPEN QUOTATIONS AS ENVISAGED IN SECTION 92 OF THE NATIONAL CREDIT ACT. DECLERATION BY CLIENT: I CERTIFY THAT ALL THE ABOVE INFORMATION IS TRUE AND CORRECT AND GRANT APPROVAL TO THE CREDIT GRANTOR TO MAKE ANY ENQUIRIES ABOUT MY CREDIT RECORD WITH ANY CREDIT AGENCY AND TO OBTAIN WHATEVER INFORMATION ON ME THAT THEY MIGHT REQUIRE TO PROCESS THIS APPLICATION.
