"Complete this form and click the "Submit" button. We will process your application for finance and advise you either by e-mail or by telephone of the outcome. Please note: All fields on this form are mandatory and need to be completed for this form to be valid and correct.
By submitting this form to us, you are under no obligation to purchase a vehicle from us. This is not an offer to purchase.
Guarantee of Confidentiality: We guarantee that the information you supply us with on this form will  be used for the sole purpose of obtaining bank finance. All information will remain confidential, and will not be divulged to any third party."
 


Applicant Type:
Individual Applicant   Soul Proprietor Surety/Co-Debtor
ID/Passport No.
Citizenship SA Other (If not SA resident, state country of Residence)
Country of Residence
Permit Type
Permit No.
PermitExpDate DD/MM/YY
Country Issued
Issue Date DD/MM/YY
Expiry Date DD/MM/YY
Surety ID No.(If appli)
Transaction Type: Instalment Sale Lease Rental
LangPref: E A Other :    
EthnicGroup A B       C W  
Dealer Code
Originating Branch
Input Branch
Credit Provider Introducing Branch
Marketer's Code
Marketers Name
Marketer's ID No.
Fax No.
Lead Provider
Lead Provider ID No.
Marital Details: S M D W No. of Dependants
Date Married DD/MM/YY
ANC COP Other
Spouse's Details: First Name
Surname
Income R
Spouses ID No./ DOB
Spouse Employer Name:
Spouse Employers Address:
Suburb
Postal Code
Relative's Details: (Nearest Relative in SA not living with you)
Relationship
Relative's Tel No.
Surname
First Name
Relative's Address:
Suburb
Postal Code
Landlord's Details: (Name & Address of Landlord where goods will be kept)
Landlord's Name:
Landlord Address:
Suburb
Postal Code
Banking Details:
Account Type: Cheque Savings Transmission
Bank Name
Branch Code
Account No.
Account Holder Name
(If appl) Overdraft Bal: R Limit: R
Credit Card Company
Credit Card Number
Cr.Facility Bal: Straight R Budget R
Cr.Facility Limit: Straight R Budget R
Existing &/or a previous Account with this Credit Provider:
Branch No.
Account No.
Account Name
Instalment Amount per month R
Number of Instalments
Current? Paid up? To be settled?
Existing accounts with other Credit Provider?
Name of Company
Account No
Instalment Amount per month - R
Current? Paid up? To be settled?
Name of Company
Account No
Instalment Amount per month - R
Current? Paid up? To be settled?
ID/Passport No.
Applicant's Income Details:
Gross Remuneration R
Monthly Commission R
Car Allowance included in Gross R
Net Take-home Pay R
Income other than Salary/Wages R
Source of Income
Total Monthly Income R
Applicant's Expenses per month:
Bond Payment / Rent R
Rates, Water and Electricity R
Vehicle Instalments(excluding those to be settled) R
Personal Loan Repayments R
Credit Card Repayments R
Furniture Accounts R
Clothing Accounts R
Overdraft Repayments R
Policy/ Insurance Repayments R
Telephone Payment R
Transport Costs R
Food and Entertainment R
Education Costs R
Maintenance R
Household Expenses R
Other R
Total Monthly Expenses R
Applicant's Disposable Income R
Date Remuneration Received: DD/MM/YY
Are you currently liable as: Surety Guarantor Co-debtor
Specify Details:
Applicant's Details:
Title Initials
Surname
First Name
Middle Name
Gender M F  Graduate? Y    N
Trading as/ Name
Tax No.
VAT No.
HomeTelNo.
Cell No.
E-mail Address
Home Address:
Suburb Postal Code
Postal Address:(If Different from Residential)  
Suburb Postal Code
Previous Home Address:
Suburb Postal Code
Employment Details:
Name
Address
Suburb Postal Code
BusTelNo.  
Fax No.  
Type of Industry
Employee No.
EmpCont No.  
Occupation
Previous Employment Details:
Name
Address
Suburb Postal Code
EmpCont No.
Occupation
Home Ownership:
Do you own your Property? Y N
(If Yes) In your name? In your Spouse's? Both?
Property Type: House Townhouse Flat
Erf Number
Suburb
Bond/Rental Payment per month: R
Bond Amount Outstanding: R
Purchase Price R
Current Value R
If a flexi/access bond, total facility granted? R
Bondholder Name
Know Your Client (KYC ): Face to Face On-Site
Face to Face Off-Site Remote-Other
Individual Applicant Sole Proprietor Surety/Co-Debtor
Transaction Details:
Goods Description
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 R
Dealer VAPS Description    
R
R
R
Delivery Fee R
Initial Fuelling Charges R
License and Registration Costs R
Initiation Fees to be financed? Y N
Less Deposit /Initial Rental R
Source of Deposit
Total R
Insurance-Bank VAPS
InSale/Lease -Inside Act
Credit Life  Monthly
Cover Plus Monthly
Extended Warranty  Term
Other
Rental - Outside Act
Credit Life Monthly     Term
Cover Plus Monthly Annual Term
Motor Comprehensive Monthly Annual    
Courtesy Car Monthly Annual    
Service & Maintenance Term
Extended Warranty Term
Other  
Comprehensive Vehicle Insurance? Y N  Policy No.   Monthly Annual
Existing Ins. Co Name   Broker Name
Tel No.     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.