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Applicants Details

Name & Surname
Address

Employment Details

Address

Home Ownership

Marital Details

Alternative contact

Banking Details

Income Details

Expense Details

Totals

Declaration

  1. I am not a minor
  2. I have never been declared unfit by a court
  3. I am not subject to an administration order
  4. I do not have a current application pending for debt review restructuring or alleviation
  5. I do not have any current debt re-arrangement in existence
  6. I have not not previously applied for debt re-arrangement
  7. I am not under sequestration
  8. I do not have any applications pending for credit, nor open quotations as envisaged in section 92 of the national credit act
I would like to be included in any telemarketing campaigns.
I would like to be included in any marketing list you may sell or distribute.
I would like to be included in any mass distribution or SMS messages.
  1. I understand that I will be liable for a monthly service fee
  2. I hereby consent to this credit provider making enquires regarding my credit history any credit bureau
  3. I consent to this credit provider reporting the conclusion of any credit agreement with me to national loans register in compliance with this credit providers obligation under the national credit act
  4. I hereby declare that the information provided by me is true and correct

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