Fill in and submit the form below to finance your next adventure.
Full Name(s)SurnameID NumberE-mailCellphoneResidential AddressLiving Status Postal AddressNext of Kin (Not living at same address)Relationship to Next of kinNext of kin Contact no.EmployerOccupationTell (W)Employer AddressNo. of Years at current employerSalary DateBank NameName of account holderAccount NumberAccount Type Basic IncomeNett IncomeBond Payment / RentPersonal Loan RepaymentsCredit Card RepaymentsFurniture AccountsTelephone AccountsClothing AccountsDSTVPolicy / Insurance RepaymentsVehicle Installments (Excl. those to be settled)
I confirm that:
I am not a minor.
I have never been declared mentally unfit by a court.
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 do not have applications pending for credit, nor open quotations as envisaged in section 92 of the National Credit Act.
I hereby grant the Credit Provider the right to communicate with me through any electronic/written media of verbally in order to make available to me, their product offering.