Microfinance Loan Application Form by kii99990

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									                                                                                              Date received:______________________

                                                                                              Loans Officer:______________________

                                               Microfinance: Loan Application Form
1.Personal Details
Surname: _____________________________             First Names: ___________________________           Title:    Mr.    Mrs.     Miss

Gender:     Male     Female           ID No. ________________________________         Date of Birth: __________________________

Residential address:___________________________              Postal address:_____________________________
                    ___________________________                             _____________________________
                    Postal code:____________                                Postal code:________________
Home Tel No.: _________________________            Cell Phone No.: ________________________

If you do not have a phone, where and how can we contact you? Name Contact Person: ________________________________________
                                                                   Tel Contact No.: __________________ Relation:___________________
2.Family Situation

Marital Status:           Married        Single       Cohabiting    Divorced       Widowed

If you are married, what is your marital regime?    Community of Property          Ante Nuptial Agreement      Traditional

Name of Spouse: ____________________________ID No. of Spouse: __________________ No. of dependants:__________________
No. of Children: ________________________             Age of Children: _________________________
Do you have anybody to run your business in your absence (sickness; maternity leave; funerals; family commitments etc)?         YES         NO

Who? Include Contact Details of person: ___________________________________ Contact detail:_______________________

Language preference___________________ Cultural Group___________________________

Disabled:    Yes     No             Nature of disability:_______________________

Are you currently employed?              Yes          No            Self-Employed        Income: R_____________

What knowledge or experience do you have that are relevant to the proposed business?
What type of business do you have/What type of business do you want to start and why?

ENF/MIC-TMP-04-03-13/01/2006                          Date: 29-08-2007                  Rev No: 01                            Page 1 of 4
3. Loan Details
Required Loan amount: R __________________            Existing Business              Business Start-Up
Application/Purpose                              Amount
1. _____________________________                 R__________________
2._____________________________                  R__________________
3._____________________________                  R__________________
4._____________________________                  R__________________
                                       Total:    R__________________

Note: The total amount should add up to your required loan amount-please attach quotations

Value of owner’s contribution (cash, stock or assets): R___________________

4. Credit History
To your knowledge, are you listed with a credit bureau?       YES      NO If yes, please explain:____________________________________
5. Personal Bank Account Details

Bank Name:                          Account Number:                    Branch Name              Type of A/C
1. _____________________            _____________________          ________________ _____________

Please attach a copy of your latest personal bank account statement.

6. Contact

How did you hear about Umsobomvu Youth Fund?_________________________Is this your first application to Umsobomvu?           Yes       No

If no, date of previous applications: _____________     Reason for decline of previous application:________________________________

7. Your Current Personal Monthly Budget/Income Statement

EXPENDITURE PER MONTH:                                            INCOME PER MONTH:

- Rent/Bond                         R ____________                - Your Salary(from business)R ___________
- Water/Electricity/Gas             R ____________                - Your spouse’s salary        R ___________
- Groceries                         R ____________                  Other, please specify:
- Clothing                          R ____________                  ________________            R ___________
- Travel/Transport                  R ____________                  ________________            R ___________
- Entertainment                     R ____________                  ________________            R __________+
- Medical Expenses                  R ____________
- Charity/Donations/Church          R ____________
- School Expenses                   R ____________
- Family Commitments                R ____________        (e.g. funerals; weddings etc)
- Insurance Fees& funeral policies R ____________
- Savings Schemes/Stokvel           R ____________
- Store Cards (clothing accounts)   R ____________
- Telephone                         R ____________
- Hire Purchase Instalments
 (furniture accounts)               R ____________
Other, please specify
- ____________________              R ____________
- ____________________              R ____________ +

TOTAL EXPENDITURE                   R ____________                TOTAL INCOME                R ___________

ENF/MIC-TMP-04-03-13/01/2006                          Date: 29-08-2007                     Rev No: 01                 Page 2 of 4
Personal assets:
Quantity     Description of asset                                            Value

Business assets
Quantity     Description of asset                                            Value

8. Referees

Ask TWO people to complete and sign the following section. Please note: persons should have known you for at least two years and one must
be a family member. They must also be contactable by telephone.

Name: ________________________________            Name: ________________________________

Occupation: ____________________________ Occupation:_____________________________

Relation to Applicant: ____________________       Relation to Applicant: _____________________

Address: ______________________________           Address: _______________________________

________________ Postal Code: __________          _________________ Postal Code: _________

Tel No.: _______________________________          Tel No.: _______________________________

Cell Phone No.: _________________________ Cell Phone No.: _________________________

9.Declaration & Signature

I confirm that neither I nor my partner(s) have ever been declared insolvent and that the above information is true and correct. I herewith give
Umsobomvu Youth Fund permission to conduct a credit history check as well as any other enquiries they may deem necessary to process this

Date:_______________________ Signature Applicant: ________________________________

Date: _______________________ Signature Spouse *: ________________________________

* Signature compulsory when married in Community of Property.

ENF/MIC-TMP-04-03-13/01/2006                         Date: 29-08-2007                   Rev No: 01                           Page 3 of 4
For Office Use Only:
Enquiry Referee 1:                               Enquiry Referee 2:

Date: _________________________________   Date: _________________________________

Spoke to: ______________________________ Spoke to: ______________________________

Comments: ____________________________    Comments: ____________________________

______________________________________ ______________________________________

______________________________________ ______________________________________

______________________________________ ______________________________________

Credit check done:     YES     NO

Checks done by: Name:_____________________    Signature:__________________            Date:__________________

ENF/MIC-TMP-04-03-13/01/2006                 Date: 29-08-2007            Rev No: 01                       Page 4 of 4

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