Individual Application Ver 1.5
Fax Number Email Address
Individual Application
Personal Details Surname First Name Middle Name/s ID/Passport New ID Citizenship Title Permit No. Permit Type Expiry date Issued Date Country of Issue Country of Res. Home Address Postal Address Previous Address Employment Details Employer’s Name Address Industry Type Previous Employer Address Industry Type Spouse’s Details Spouse Name ID Number Employer Relative’s Details Relationship Address Home Ownership Own Property? Bond/Rental PM Bond Outstanding Bond Holder Name Individual Applicant Instalment Sale Surety ID (if applicable) New Used Sole Proprietor Lease Surety/Co-Debtor Rental Y R R N In your Name? In Your Spouse’s? Both? House Townhouse Flat Phone Surname First Name Postal Surname DOB Address Employee No. Occupation Employee No. Phone Occupation Fax Phone Fax Postal Period Cont. No Postal Period Y M Y M Cont. No SA Initials Cell No Email Gender Graduate? Trading as Language E A Other Ethnic Group A Period Postal Period Y M B Y C W M M Y F N Married Date Married Other Tax No. VAT No. Home No Dealer Code Originating Branch Input Branch Marketer Marketer’s ID Lead Provider Lead Provider ID Tenant Lodger Divorced Single ANC COP Widowed Other
Purchase Price R Current Val. R
If Flexi/Access Bond, Total Facility R Erf No.
Individual Application Ver 1.5
Banking Details Account Type Branch Code Account Holders Name Overdraft Credit Card Coy. Cr Facility Bal Straight R Cr Facility Limit Straight R R R R R Overdraft Limit Credit Card No. Cr Budget Cr Limit Budget Cheque Savings Transmission Bank Name Account No. R R R R
Existing and/or a previous Account with this Credit Provider Branch No Account Name Instalment Amount PM Existing accounts with other Credit Provider Company Name Account No. Monthly Instalment R R Landlord's Details (Where the goods will be kept) Name Income Details Spouses Income Basic Salary + Car Allowance + Income Other than Salary, overtime, Shift allowance etc. + Monthly Commission Total Monthly Income Net Take Home Pay Other Source of Income - trusts, maintenance, Rent Please Specify Total Household Expenses Bond Payment/Rent Rates, Water, Electricity Vehicle Instalments (Excluding those to be settled) Personal Loan Repayments Credit Card Repayments Furniture Accounts Clothing Accounts Overdraft Repayments Medical Aid Pension Total Monthly Expenses Applicants Disposable Income Specify Details of liability R R R R R R R R R R R R Policy/Insurance Repayments Telephone Payment Transport Costs Food and Entertainment Education Costs Maintenance Household Expenses UIF Total Tax Other Salary Date Are you liable as: Surety Guarantor Co-Debtor R R R R R R R R R R R R R R R R R Address Postal Current Paid Up To be Settled Number of Instalments Account No. Current Paid Up To be Settled
Individual Application Ver 1.5
Insurance-Bank VAPS Instalment Sale/Lease Inside the NCA Credit Life Monthly Cover Plus Monthly Extended Warranty Term Other Insurance-Bank VAPS Rental – Outside the NCA Credit Life Cover Plus Motor Comprehensive Other Insurance Company Name Policy No. Broker Name Transaction Details Goods Description Year Model Scheme Code Purpose of Goods Business Salesman Buy line Code Private Bi-Ann Arrears % % % Balloon Payment Residual Payment Fixed R R R R R Linked Taxi Quart Cash R R Dealer VAPs Delivery Fee Initial Fuelling Charges Licence and Registration Costs Less Deposit / Initial Rental Grand Total Commerce Annual Debit Order Dealer Name Dealer Phone M&M Code Contract Period (Mths) Special Requirements Odometer Km’s Initiation Fees to be Financed R R R R R R Y N Monthly Monthly Monthly Annual Annual Term Term Service & Maintenance Extended Warranty Term Term
Comprehensive Vehicle Insurance Phone Monthly Phone Annual
Payment Frequency Months Payment Mode Balloon Payment Residual Value Proposed Rate Advance
Selling Price (VAT Inclusive) Extras Extras Extras Total Extras Source of Deposit Know Your Customer Face to Face on-Site I confirm that:
Face to Face Off-Site
Remote Other
I do not have applications pending for credit, nor open quotations as envisaged in section 92 of the National Credit Act. If any of the above is incorrect, state which and give details:
(a) (b) (c) (d) (e) (f) (g) (h) (a) (b) (c)
I am not a minor. A court has never declared me mentally unfit. I am not subject to an Administration Order. I do not have any current application pending for debt restructuring or alleviation. I do not have any current debt re-arrangement in existence. I have not previously applied for a debt re-arrangement. I am not under sequestration.
I would like to be included in any Telemarketing Campaign. I would like to be included in any Marketing List that you may sell or distribute
Y/N Y/N
I would like to be included in any mass distribution of emails or SMS messages. Y/N I understand that I will be liable for a monthly service fee. I hereby consent to this Credit Provider making enquiries regarding my credit history with any credit bureau. I consent to this Credit Provider reporting the conclusion of any credit agreement with me to the National Loans Register in compliance with this Credit Provider ’s obligation under the National Credit Act. I hereby declare that the information provided by me is true and correct.
Signature of Applicant
Date