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Customer Information

Personal Information

Title

Initials

Surname

Full Names

ID Number

Postal Address

Postal Code

Residential Address

Postal Code

Home Telephone Number

Cell Phone Number

Employment Information

Employer

Department

Supervisor

Work Phone Number

Pay Date

Employee Number

Start Date

Basic Salary

Deductions

Loan Amount

Next of Kin

Name

Tel. Number

Address

Postal Code

Marital Status

Spouse

Name

Tel. Number

Address

Postal Code

Credit Bureau Authorization

I hereby authorize the Lender to do a Credit Bureau enquiry on me at any Credit Bureau of his choice.

Agent/Merchant

Agent/Merchant

Tel. Number

Email Address