Loan Application Form

Applicant Personal Details

Agent Code:


Loan Amount :
Loan Term:
Email Address: Title:
Name: Surname:
Language: ID:
Cell Number: Home Number:

Physical Address

Postal Address

Address: Address:
Postal Code: Postal Code:
City: City:

Friend or Relative

Friend or Relative (2)

Name: Name:
Cell: Cell:
Address: Address:

Pre-Qualify & Marketing Information

Own or joint Bank Account with 2 months Salary deposited?
Are you under the following?
1)Administration 2)Debt Councelling 3)Debt Review
4)Sequestration 5)Liquidation
Can we include Credit Life Cover?
Marrital Status
Loan Purpose :

Employment Details

Gross Salary: Net Salary:
Company Name: Period Employed:
Department: Payment Frequency:
Salary Pay Date: Employment Status:

Living Expences

Rates/ Water & Electricity: Cell/Tel/Airtime:
Maintanace/Children Bond/Rent:
Groceries: Education/School/Day Care:
Transport/Fuel/Taxi: Life Insurance / Investemnts:
Credit Card: Car Insurnance:
Personal Loans / Micro Loans: Furniture / Other HP:
Clothing: Other:

Banking Details

Bank Name:
Account Holder:
Account Number:
Account Type:
Branch Code:
Branch Name:

Terms and Conditions

I declare that the above information is true and correct. This application is subject to final approval and may be accepted or rejected by the Credit Provider at its sole discretion, subject to it's final credit assessment process.

I consent to the Credit Provider making enquiries about my credit record with any credit reference agency or with any party as per the information provided by me. I further consent to the Credit Provider carrying out identity and fraud prevention tests.

I also hereby authorize the Credit Provider to obtain a credit report from a credit bureau for purposes of an assessment prescribed by Section 81.

I Agree

Agree to continue