Online

Name *

First

Last

Your ID No *

Date of birth *

Email *

Cell no *

Tel(H) *

Language *

Marital status *

If Married

If Married: Anniversary date

Dependents

Selected Value: 0

Age:

Home address *

Residing duration (years)

Selected Value: 0

Previous address *

Residing duration (years)

Selected Value: 0

Driver's license *

Driver's license code

Year license first issued

Selected Value: 1970

Employer *

Branch *

Dept. *

Occupation *

Duration at company (Years)

Selected Value: 0

Salary (gross) *

Salary (nett) *

Tel(w) *

Previous employer

Duration (Years)

Selected Value: 0

Spouse Name

First

Last

Cell no

Tel(w)

Spouse Employer

Branch

Occupation

Dept.

Duration at company (Years)

Selected Value: 0

Salary (gross)

Salary (nett)

Other income

Source

Amount

Any previous financial problems

HAVE YOU GOT SOMEONE WHO WILL SIGN SURETY FOR YOU? *

Name *

First

Last

Relationship *

Name and address of nearest relative not living with you (1) *

Relationship *

Tel (H) *

Tel (W) *

Cell no *

Name and address of nearest relative not living with you (2) *

Relationship *

Tel (H) *

Tel (W) *

Cell no *

Are you currently liable as surety or co-debtor? *

Specify details

Amount owing

Bankers

Branch

Acc type

Acc no.

Fixed deposit:

Amount

Do you own or rent a house? *

Date purchased

Purchase price

Bond

Current value

Bond holder

Who's name

TRADE REFERENCES 1. Company

Branch

When bought

Acc no

Paid/current

TRADE REFERENCES 2. Company

Branch

When bought

Acc no

Paid/current

TRADE REFERENCES 3. Company

Branch

When bought

Acc no

Paid/current

TRADE REFERENCES 4. Company

Branch

When bought

Acc no

Paid/current

Bond payment/rent *

Rates, water and electricity *

Clothing accounts *

Furniture accounts *

Telephone payments *

Education costs *

Food and entertainment *

Maintenance *

Personal loans *

Insurance policies *

Credit card payments *

Vehicle instalments *

Transport cost *

Overdraft payments *

Other *

GROSS TOTAL *

Household income details: Car allowance:

Other income

Total nett income (all combined) *

Disposable income *

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.