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WELCOME _ IF WE CANT HELP YOU, NO-ONE CAN
This form is secure and your information is save and protected. Also please note that we DO NOT sell or trade your personal information as per the Protection of Personal Information Act (POPI Act)
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1
HOW DID YOU HEAR ABOUT US?
*
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WHATSAPP/FACEBOOK
INSTAGRAM
REFERRED -(FRIENDS/FAMILY/CO-WORKER)
Other
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2
Do you have a Home loan?
Are you currently still paying on your home loan?
YES
NO
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3
Do you have Vehicle?
Are you currently still paying your vehicle?
YES
NO
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4
Name & Surname (Applicant)
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5
ID Number (For Credit Check)
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*PLEASE NOTE - This will be used to assess your credit report & to determine the proper assistance required.*
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6
Address
Please fill your address for compliancy purposes.
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7
Email
joe@smithee.co.za
Confirm Email
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8
Mobile Number
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eg: 083
1234567
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9
Marital Status
Married (COP)
Married (ANC without accrual)
Married (ANC with accrual)
Single
Traditional
Single
Married (COP)
Married (ANC without accrual)
Married (ANC with accrual)
Single
Traditional
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10
Name & Surname (Spouse)
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11
Spouse Mobile Number
Area Code
Phone Number
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12
Next of Kin (Not Living with you)
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13
Bank Details
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Please make sure this bank account is in YOUR NAME for the ease processing and Forensic Credit Audits.
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14
Employer Details:
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Please make sure that the information here correspond with your PAYSLIP.
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15
Spouse Employer Details:
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16
Food
*
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How much do you spend on food monthly?
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17
Rent/Bond
*
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How much do you pay for rent / on your bond?
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18
Clothing
*
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How much do you spend on clothing each month?
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19
Traveling/Petrol
*
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How much do you give out on travelling / petrol each month?
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20
Water/Electricity
*
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How much do you spend on rates & water and/or Electricity each month?
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21
CellPhone/Data
*
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How much do you send on your cellphone (Data, calls, sms etc) each month?
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22
School/University Fees
*
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How much do you spend on your kids school fees/creche fees/ your studies(University) each month?
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23
Telephone
*
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How much do you spend on you landline / your mobile contract each month?
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24
Bank Charges
*
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How much is your bank charges each month?
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25
Insurances / Policies
*
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What do you spend on Insurances and/or Policies each month?
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26
TOTAL MONTHLY EXPENSE
This is what your expenses is roughly each month.
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27
Creditors List - (Current Creditors, and/or Under Debt Review)
*
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Please list your creditors & monthly repayments towards creditors, store accounts, Personal loans, Home Loan, Vehicle finance, credit cards etc... [TO ADD MORE CREDITORS PRESS "Add another Creditor"]
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28
Signature please, I declare/Agree that the above information is correct.
*
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for POPI Compliancy (T's & C's Apply)
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29
WE TAKE ALL THE RISK, SO THAT YOU DON'T NEED TO
*APPLICATION FEES* _ MONEY BACK GUARANTEED IF WE CANT GET YOU AN INFORMED RESULT/OUTCOME.
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30
Signed at
Client City/Province
*
. On the
Date
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31
My Products
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My Bag
1
My Bag
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Great Product Name
$20
Quantity:
1
Size:
Small
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Edit
Great Product Name
$20
Quantity:
1
Size:
Small
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Great Product Name
$20
Quantity:
1
Size:
Small
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Great Product Name
$20
Quantity:
1
Size:
Small
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ORDER SUMMARY
Total cost
USD
Affordable Debt Distribution
Affordable Debt Distribution for your current Debt. This service is compulsory with any of our services. @R79 p/m (Contractual Agreement Fee) THIS IS NOT DEBT REVIEW.
$
Free
+
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Old Debt Management (Easy Setllements)
Get up to 40% Off on your Old Outstanding Debt and pay your new revised settlement amount over 37months. @R79 p/m (Contractual Agreement)THIS IS NOT DEBT REVIEW.
$
Free
+
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Red Flag _ITC Clearance (SA)
100% Money Back Guarantee if the work done within 60days (T's&C's) Payment Terms Available - WE REMOVE: DEBT REVIEW, DEFAULTS, JUDGEMENTS, ADMINISTRATION ORDERS &GARNISHEE ORDERS ASWELL.
$
Free
+
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Payment Holiday
Payment Holiday is the service that allows a consumer to take 1-2 month break from paying the creditors. @ R900 ex Vat. once-fee
$
Free
+
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