Individu ‘Applicant Typ. Individual Applicant [] Sole Proprietor 1] surety/Co-Debtor C] 1ssport No. Citizenship SAC] Other [] «arnot SA resiien, state country of Resiience) Country of Residence. Permit Type. Permit No, PermitéxpDate J /_pormww| Country Yssued Issue Date__/ / _oommry Expiry Date__/_/__ corm] Surety 1D No. (apa eS Transaction Type: Instalment Sale] Lease] _ rental LangPref: EC] aL] other[] ethnicGroup: aL] 8 C) c C) wi Title Initials a ‘Surname. =e First Name. Middle Name Genderm ] FL) Graduate? YO) Trading as/ Name Tax No. VAT No. HomeTeiNo. (___} Cel No. E-mail Address (ve intne _— Postal Code Postal Code Bibb eee Previous Home Addressi(vra_ nex) __ |Spouse's:Detatiist Name ~Jlandiqrd’s Details: (nome 8 address of Landlord where geod wi be fest) ~] Landlord's Nam: jal Application for Finance Dealer Code originating Branch Input Branch Credit Provider Introducing Branch ___|__ ea Marketer's Code. Marketers Name Marketer's ID No., Lead Provider Lead Provider 1D No. Fax Now MC] 0D] WO No. of Dependants Date Married —~_4_coormmy) ANCL] cop) orher C) Income R__] [Surmame, Spouses ID No./ DOB Postal Code rest Relative n SA ot ving wth you) Relationship Relative's Tel No. [Suname. First Name: [Suburb Postal Code Landlord Address: Suburb Postal Code Suber, Postal Code is_at Name - neque C] Savings transmission (] Address Bark Name Branch Code. ‘Suburb Postal Code Account No. BusTelNo(___) Fax No, Type of Industry Employee No | EmpCont No.(___} Occupation. Previous Employment Details:(v1s_winins—} Name Address Suburb Postal Code. EmpCont No. {__})Oecupation yO sO Do you own your Property? tyes) In your name?) _ In your Spouse's? ] Both? CL] Property Type: House C) ‘Townhouse C] Frat Erf Number, Suburb, Bond/Rental Payment per month: R___ Bond Amount Outstanding a Purchase Price Current Value B Ifa flex/access bond, total faciity grantec?) R_____ Bondholder Name, —————F ranch Wo. Account Holder Name lar sppn Overdraft Bat: R= Limit @ [credit Card Company Credit’ Card Number [cr.Faciity Bal:* straight =. Budget a______| Cr.Faclity Lilt: Straight & Budget & Existing &/or a previous Account with this Credit Provider [Account No. [Account Name {instalment Amount: per month. Number of instalments: [current2-C]'\ pai up?) To be settied? Existing accounts with other Credit Provider? Name of Company JAccount No ee Instalment. Amount per: month Current? (] _ Paid up? 1) Hare of Company — To be settled? L] Face to Face On-site Remote-Other Know Your Client (KYC ): Face to Face Off-site C] Qo Account NO finstalment Amiount per month = R. current? [] Paid up? LJ To be settled?Individual Applicant (] Sole Proprietor [] Surety/Co-Debtor (1 ‘Transaction Details: Goods Description JGross Remuneration Bp Monthly Commission 2 [Car Allowance included in Gross R Net Take-home Pay | [income other than Salary/Wages a Source of Income Year Model____ Salesman Dealer Name Dealer Tel No. Scheme Code Buyline Code MaM Code Period of Contract rts) Special Requirements, . Balloon Payment % = R g Gseseseeeeoncesel | Residual Value % = R Purpose of Goods: Business [] Private (] taxi [) commerceL]{ Bond Payment / Rent i | Payment Frequency: MonthL] Bi-Ann L) quart] Annual C]Rates, Water and Electricity Ra relenincieeell Payment Mode: Advance L] arrears] cash C1] DebitorderL_]| vehicle instalments (excising hore tobe settes) Rs Personal Loan Repayments & Applicant's Financial Details: Creat Card Repayments Proposed Rate __ 9% Fixed] Linked] | Furniture Accounts Selling Price (VAT inclusive) z Clothing Accounts Extras Description _____ a Poverdraft Repayments ae Policy/ Insurance Repayments Foo Fretephone Payinent R B transport Costs 2 Total of extras R Food ad Etertainmient ~ | Dealer VAPS Description BR feaueation costs | aera a Maintenance 2 I pousehoid exrenses ee Delivery Fee RJ other . 2 Initial Fueling Charges | 2 License and Registration Costs ae Initiation Fees to be inancea? YC] nC) ET =k elope artical z Date Remuneration Received: _/__/ _panmvw |Are-you curtently Wable as: Surety (] Guarantor (] Co-debtor 1] Specify Details: Source of Deposit Total hinsurance-Bank VAPS InSale/Lease -Inside Act Rental - Outside Act edit Life Monthly C) Credit Life Monthly 2) Term (| Service & Maintenance Term cover Plus Monthly [) Cover Plus Monthly [3], Annual C) Term (]] Extended Warranty Term O extended Warranty Term D]} motor Comprehensive Monthly C} Annual [] Other o Jother___ CO) Courtesy car Monthly [Annual [] |Comprehensive Vehicle Insurance? YC] N[] Policy No. Monthly] Annual C] TelN.{ Broker Name. Jel No..£ 1 Tam not a minor B. Ihave never been declared mentally unfit by 8 court C._Tam not subject to an Administration Order 1. To not have any current application pending for debt restructuring or alleviation. E. To not have any current debt re-arrangement in existence. F._Thave not previously applied fora debt re-arrangement. G. 1am not under sequestration H. [do not have applications pending for credit, nor open quctations as envisaged in sedtioh 92 ofthe Natio Cred Act If any of the above Is incorrect, state which and alve detalls 1. Twould tke to be included in any Telemarketing Campaign: yO sO J.T would lke to be included in any Marketing List that you may sell or distribute yO~-nO K.-T Would like to be included In any mass distribution of emalis or SMS messages. yO- sO 1 understane that I wil be lable for a monthly sevice fe. Thereby consent to this Crelt Provider making enqulres regarding my credit history with any credit bureau, 1 consent to this Creit Provider reporting the conclusion of any creit agreement with me tothe National Loans Register In compllance with this Credit Provider's obligation under the National Crecie Ack. Thereby deciare tat the information provided by més true and correct.