Pre-Application Form

1

Are you new customer with MAXIMA?* This field is required.

Yes

No

2

Do you remember your MID?* This field is required.

YesNo

3

Input your MID* This field is required.

4

What is your name in Khmer?* This field is required.

5

What is your name in Latin?* This field is required.

6

What is your gender?* This field is required.

Female

Male

7

What is your date of birth?* This field is required.

8

What is your marital status?* This field is required.

9

What is your phone number?* This field is required.

10

Please select your current address and if you don't see your province on the list, we apologize because we are operating only these provinces* This field is required.

11

Your current address

12

What is your living status?* This field is required.

13

Living Status* This field is required.

14

How many months do you live in this village?* This field is required.

15

How many months do you live in this rental house/room?* This field is required.

16

What's type of your career?* This field is required.

17

Career Type

18

What is your position?* This field is required.Please write it in Khmer

19

What is your business about?* This field is required.Please write it in Khmer

20

Career Detail* This field is required.

21

How many months are you working with this workplace?* This field is required.

22

How many months are you doing with this business?* This field is required.

23

What is the name of your former company?* This field is required.

24

How long did you work with your former company?* This field is required.

25

Duration of doing this career

26

How did you know about this loan?* This field is required.

27

What type of loan would you prefer?* This field is required.

28

Loan Type

29

Please select loan currency* This field is required.

KHR

USD

30

How much loan amount do you want to apply (KHR)?* This field is required.

31

How much loan amount do you want to apply (USD)?* This field is required.

32

Loan Origin

33

How many months of the loan terms do you prefer?* This field is required.

34

Do you have a loan collateral?* This field is required.

Yes

No

35

What is your loan purpose?* This field is required.

36

When do you need this loan?* This field is required.Please select at least tomorrow date except weekend and holiday in case you are doing this application in after 1PM.

37

Please take photo of your National ID Card/Family Book/Resident Book.* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 20.0MB

38

Please pin your living location on the google maps. You can ignore it if you don't want to complete it this time.

39

This is your living location on google maps that you pin

40

Unique MID

41

MID Generator, Please ignore this because it's just system generated.* This field is required.

42

Your MID Number* This field is required.Please note this MID number for your future reference

43

Name

First Name

Last Name

44

Email

example@example.com