Hessequa Research form

1
Choose your Municipality:
Please Select
Please Select
1.Richtersveld municipality (Portnolloth)
2.Namakhoi municipality ( Springbok)
3.Kai Ma municipality (Pofadder)
4.Kai Garieb municipality (Kakamas, Keimoes)
5.Ikheis municipality ( Groblershoop)
6.Siyatemba municipality (Prieska)
7.Beaufort West Municipality
8.Laingsburg municipality
9.Oudshoorn municipality
10.Kannaland municipality (Ladysmith)
11.Dawid Kruiper Local Municipality (Upington)
2
Choose Your Language?* This field is required.
Afrikaans
English
3
Terms and Conditions* This field is required.
4
What is your name?* This field is required.
First Name
Last Name
5
What is the best way to reach you?* This field is required.
e-mail
mobile number
WhatsApp
6
What is your Phone Number?* This field is required.
Please enter a valid phone number.
7
What is your e-mail? Don't worry if you don't have one just skip the question
example@example.com
8
How old are you?* This field is required.
Please Select
Please Select
• Under 18
• Between 18 -25
• Between 26 – 30
• Between 31-40
• Between 41-50
• Between 51-60
• Older than 60
9
Are you married? * This field is required.
Yes
Unmarried
In a relationship
10
How many people are depending on you for a home? * This field is required.
Please Select
Please Select
Just me
2
3
4
5
more
11
Do you work? * This field is required.
YesNo
12
Who do you work for? * This field is required.
13
How much do you earn per month? * This field is required.This amount is your salary before any deductions including tax & payroll
Please Select
Please Select
Less than R 3500 per month
Between R 3500 & R 5000 per month
Between R 5000 & R 8000 per month
Between R 8000 & R 12 000 per month
Between R 12 000 & R 18 000 per month
Between R 18 000 & R 22 000 per month
Between R 22 000 & R 28 000 per month
More than R 28 000 per month
14
What is your households combined monthly income? * This field is required.Before deductions
15
Are you currently on a waiting list of the municipality for a house?* This field is required.
YESNO
16
What is your Reference Number on the waiting list?
17
What is your credit score?* This field is required.
Good
Bad
Medium
None
Don't know
18
In what type of property would you stay? * This field is required.
Free Standing home
Apartment
Other
19
If you own your own home or apartment and you receive a loan how much would you be able to pay per month?* This field is required.
Please Select
Please Select
Nothing
• R1 000.00 - R2 500.00 per month
• R2 501 – R3 500.00 per month
• R3 501 – R4 500.00 per month
• R4 501- R 5 500.00 per month
• R5 501 – R6 500.00 per month
• R6 501 – R 7 500.00 per month
• R7 501.00 – R8 500.00 per month
• R8 500.00 – R9 500.00 per month
• R9 5001 – R10 500.00 per month
• R10 501 – R12 500.00 per month
• R12 501 - R 14 500.00 per month
• R14 501- R16 500.00 per month
• More than R16 500.00 per month
20
Do you currently own a home or apartment? * This field is required.
YESNO
21
Have you ever owned a property in your own name or with a spouse or partner?* This field is required.
YESNO
22
Please provide your current address?* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
23
Toestemmming* This field is required.
24
Wat is jou naam? * This field is required.
Naam
Van
25
Beste manier om jou te kontak vir terugvoer?* This field is required.
e-pos
Selfoon
WhatsApp
26
Wat is jou kontak nommer?* This field is required.
Please enter a valid phone number.
27
Wat is jou e-pos?
example@example.com
28
Hoe oud is jy? * This field is required.
Please Select
Please Select
• Onder 18
• Tussen 18 -25
• Tussen 26 – 30
• Tussen 31-40
• Tussen 41-50
• Tussen 51-60
• Ouer as 60
29
Is jy getroud?* This field is required.
Ja
Ongetroud
ongetroud maar in 'n verhouding
30
Hoeveel mense moet jy voor sorg vir blyplek?* This field is required.
Please Select
Please Select
Net Myself
2
3
4
5
meer
31
Werk jy tans? * This field is required.
JaNee
32
Vir wie werk jy? * This field is required.
33
Hoeveel verdien jy per maand – voor aftrekkings?* This field is required.
Please Select
Please Select
• R1 000.00 - R3 500.00 pm
• R3 501 – R6 000.00 pm
• R6 001 – R10 000.00 pm
• R10 001 – R13 000.00 pm
• R13 001 – R16 000 pm
• R16 001 – R19 000 pm
• R19 001 – R22 000.pm
• R22 001 – R28 000.pm
• R28 001 – R33 000.pm
• R33 001 – R40 000.pm
• Meer as R40 0001 pm
34
Totale huishoudelike inkomste per maand – voor aftrekkings* This field is required.
35
Is jy tans op ‘n waglys van die munisipaliteit vir ‘n huis?* This field is required.
JaNee
36
Wat is u verwysings nommer op die waglys?
37
Wat is jou kredietrekord tans?* This field is required.
• Goed
• Gemiddeld
• Laag
• Geen
• Ek weet nie
38
In watter tipe huis sal jy wil bly? * This field is required.
• Huis
• Woonstel
• Ander
39
Wat is jou huidige Adres?
Straat Adres 1
Straat Adres 2
stad
Provinsie
Poskode
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
40
As jy jou eie huis/woonstel besit en ‘n lening by ‘n bank het, hoeveel sal jy elke maand wil of kan terugbetaal? Tussen:* This field is required.
Please Select
Please Select
• R0 – kan niks betaal nie
• R1 000.00 - R2 500.00 per maand
• R2 501 – R3 500.00 per maand
• R3 501 – R4 500.00 per maand
• R4 501- R 5 500.00 per maand
• R5 501 – R6 500.00 per maand
• R6 501 – R 7 500.00 per maand
• R7 501.00 – R8 500.00 per maand
• R8 500.00 – R9 500.00 per maand
• R9 5001 – R10 500.00 per maand
• R10 501 – R12 500.00 per maand
• R12 501 - R 14 500.00 per maand
• R14 501- R16 500.00 per maand
• Meer as R16 500.00 per maand
41
Besit jy tans jou eie huis of woonstel?* This field is required.
Janee
Should be Empty: