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Application Form

Applicant type: Dealer Code:
Individual Applicant    Sole Proprieor    Surety/Co-Debtor Originating Branch: Input Branch:
ID/Passport NO: Credit Provider Introducing Branch:
Citizenship SA   Other (If not SA resident, state country of Residence) Marketer's Code:
Country of Residence:   Permit Type: Marketer's Name:
Permit No:   PermitExpDate: (DD/MM/YY) Marketer's ID No: Fax No:
Country Issued: Lead Provider:
Issue Date: (DD/MM/YY)  Expiry Date: (DD/MM/YY) Lead Provider ID No:
Surety ID No. (If Appl):( DD/MM/YY) Marital Details: S    M    D W  No of Dependants:
Transaction Type: Installment Sale    Lease    Rental Date Married: (DD/MM/YY)   ANC    COP    Other
Lang Pref: E    A    Other Ethnic Group: A    B    C   W Spouses Details: First Name
Applicant Details: Surname:   Income:R
Title:   Initials: Spouses ID No./DOB:
Surname: Spouse Employer Name:
First Name:   Middle Name: Spouse Employers Address:
Gender: M    F        Graduate? Yes No Suburb:    Postal Code:
Trading as/Name: Relatives Details:(Nearest relative in SA not living with you)
Tax No:   VAT No: Relationship:   Relative's Tel No:
Home Tel No: (0123217654)  Cell No: Surname:
Email Address: First Name:
Home Address:( Yrs:    Months:  )  Relatives Address:
Suburb: Postal Code:
Suburb:   Postal Code: Landlord Details:(Name & Address of Landlord where goods will be kept)
Postal Address:(If different from Residential)  Landlord's Name:
Landlord's Address:
Suburb:   Postal Code: Suburb: Postal Code:
Previous Home Address:( Yrs:    Months:  )   
Banking Details:
Suburb:   Postal Code: Account Types: Cheque:    Savings:    Transmission: 
Employment Details:( Yrs:    Months:  ) Bank Name:   Branch Code:
Name: Account No:
Address: Account Holder Name:
Suburb:   Postal Code: (If Appl) Overdraft Bal:R   Limit:R
BusTelNo: (0123217654)  Fax No: Credit Card Company:
Type of Industry:   Employee No: Credit Card Number:
EmpCont No: (0123217654)  Occupation: Cr Facility Bal:Straight R   Budget:R
Previous Employment Details:( Yrs:    Months:  ) Cr Facility Limit:Straight R   Budget:R
Name: Existing &/or a previous Account with this Credit Provider:
Address: Branch No:
Suburb:   Postal Code: Account No:
EmpCont No: (0123217654)  Occupation: Account Name:
Home Ownership: Installment Amount per month:R
Do you own Property ?: Y    N  Number of Installments:R
(If Yes): In your name?    In your Spouse's?    Both? Current?:  Paid up?:    To be settled?: 
Property Type: House    Townhouse    Flat Existing accounts with other Credit Providers?
Erf Number:   Suburb: Name of Company:
Bond/Rental Payment per month:R Account No:
Bond Amount Outstanding:R Installment amount per month:R
Purchase Price:R Current?:  Paid up?:    To be settled?: 
Current Value :R Name of Company?:
If a flexi/access bond, total facility granted?:R Account No?:
Bondholder Name?:R Installment amount per month:R
Know your client ?: Current?:  Paid up?:    To be settled?: 
Face-to-Face On-Site Face-to-Face Off-Site   Remote Other:  
   
Transaction Details: Goods Description
Applicant's Income Details:
Gross Remuneration
Monthly Commission
Car Allowance included in Gross
Net Take-home Pay
Income other than Salary/Wages
Source of Income
Total Monthly Income
Applicant's Expenses per month:
Bond Payment / Rent
Rates, Water and Electricity
Vehicle Instalments (excluding those to be settled)
Personal Loan Repayments
Credit Card Repayments
Furniture Accounts
Clothing Accounts
Overdraft Repayments
Policy/ Insurance Repayments
Telephone Payment
Transport Costs
Food and Entertainment
Education Costs
Maintenance
Household Expenses
Other
Total Monthly Expenses
Applicant's Disposable Income
Date Remuneration Received:
Are you currently liable as:Surety Guarantor Co-debtor
Specify Details:
Year Model: Salesman:
Dealer Name: Dealer Tel No.
Scheme Code: Buyline Code:
M&M Code: Period of Contract (Mnths):
Special Requirements:
Balloon Payment: % R
Residual Value: % R
Purpose of Goods: Business Private Taxi Commerce
Payment Frequency: Month Bi-Ann Quart Annual
Payment Mode: Advance Arrears Cash DebitOrder
Applicant’s Financial Details:
Proposed Rate % Fixed Linked
Selling Price (VAT inclusive) R
Extras Description: R
R
R
R
Total of Extras
Dealer VAPS Description R
R
R
Delivery Fee
Initial Fuelling Charges
License and Registration Costs
Initiation Fees to be financed? Y N
Less Deposit /Initial Rental
Source of Deposit
Total
   
   
Insurance-Bank VAPS
InSale/Lease -Inside Act
Rental - Outside Act
Credit Life Monthly Credit Life Monthly Term Service & Maintenance Term
Cover Plus Monthly Cover Plus Monthly Annual Term Extended Warranty Term
Extended Warranty Term Motor Comprehensive Monthly Annual Other
Other Courtesy Car Monthly Annual  
Comprehensive Vehicle Insurance? Y N Policy No. Monthly Annual
Existing Ins. Co Name Tel No. Broker Name Tel No.
 
I confirm that: -    
  A. I am not a minor.    
  B. I have never been declared mentally unfit by a court.    
  C. I am not subject to an Administration Order.    
  D. I do not have any current application pending for debt restructuring or alleviation.    
  E. I do not have any current debt re-arrangement in existence.    
  F. I have not previously applied for a debt re-arrangement.    
  G. I am not under sequestration.    
  H. 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:    
  I. I would like to be included in any Telemarketing Campaign. Y N
  J. I would like to be included in any Marketing List that you may sell or distribute Y N
  K. 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