INDIVIDUAL APPLICATION FORM
KIA N1 CITY - DWAYNE JANSEN
Personal Details
Name
*
First Names
Last Name
ID Number
*
Gender
Male
Female
Status
*
Single
Married
Seperated
Divorced
Widowed
If married, what date did you get married?
How are you married?
Community of Property
Antenuptial
Tribal
Highest Qualification
*
TELEPHONE NUMBERS
Phone Number
*
Format: (000) 000-0000.
Email
*
example@gmail.com
RESIDENTIAL ADDRESS
Current Address
*
Street Address
City
Province
Area Code
Period living at address
Residential address ownership
*
Living with Family
Renting
Homeowner
If Home Owner, is your home Bonded or are you Bond Free?
Bonded
Bond Free
If Bonded, which bank financed your home?
Which date was your home purchased?
Occupation Details
Employment Category
*
Employed
Self Employed
Pensioner
Type of Industry
*
Employer Name
*
Occupation
*
Employer Address
*
Salary Date
*
Company Phone Number
*
Format: (000) 000-0000.
Period at employer
*
Income
Monthly Gross Income
*
in Rand
Monthly Net Income
*
in Rand
Other Income
in Rand
Source of Other Income
Monthly Expense
BOND / RENT
RATES / WATER / ELECTRICITY
PERSONAL LOANS
CREDIT CARD
FUEL COST
TELEPHONE / INTERNET
FOOD / ENTERTAINMENT
EDUCATION
FURNITURE ACCOUNTS
CLOTHING ACCOUNTS
POLICY PAYMENTS
INSURANCE COSTS
OVERDRAFT
MAINTENANCE
VEHICLE REPAYMENT (NOT TRADING IN)
SECURITY EXPENSES
OTHER COSTS
Spouse Details (If Married)
NAME
SURNAME
ID Number
Cellphone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Next of Kin Details (Relative / Friend NOT LIVING WITH YOU)
Name
*
Surname
*
Relationship with Person
*
Residential Address
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Banking Details
Bank Name
*
Account Number
*
Account Type
*
Current
Saving
Preffered monthly debit date
*
Vehicle Details
Make & Model
New or Used
Preffered Finance
Payment
Cash
Finance
Preffered Monthly Installment
Terms
72 Months
84 Months
Step Payment
Do you have a deposit?
YES
NO
I confirm that:
I am not a minor.
I have never been declared mentally unfit by a court.
I am not subject to an Administration Order.
I do not have any current application pending for dept restructuring or alleviation.
I do not have any current dept re-arrangement in existence.
I have not previously applied for a dept re-arrangement.
I am not under sequestration.
I do not have applications pending for credit, nor open quotations as envisaged in section 92 of the National Credit Act.
I hereby give consent to the Credit Provider to make enquiries about my credit record with any credit agency and to obtain whatever information on me they might require to process the application. I also give consent to the credit provider to share my payment behaviour with any credit agency.
I hereby give consent to the Credit provider to make enquiries about my credit record with any credit agency and to obtain whatever information on me they might require to process the credit application and / application for insurance.
I understand that I will be liable for a monthly service fee.
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.
Signature
*
Submit
Should be Empty: