Individual Application for Finance

Applicant Type: Individual Applicant Sole Proprietor Surety/Co-Debtor ID/Passport No. (If not SA resident, state country of Residence) Citizenship SA Other Country of Residence Permit Type Permit No. PermitExpDate / / DD/MM/YY Country Issued DD/MM/YY Expiry Date / / DD/MM/YY Issue Date / / Surety ID No. (If appli) Transaction Type: Instalment Sale LangPref: E A Other Lease B Rental C W EthnicGroup: A

Dealer Code Originating Branch Credit Provider Introducing Branch Marketers Code Marketers Name Marketer's ID No. Lead Provider Lead Provider ID No. Marital Details: S M D W Input Branch

Fax No.(

No. of Dependants

Applicants Details: Title Initials Surname First Name Gender M F Trading as/ Name Tax No. HomeTelNo. ( ) E-mail Address Home Address: (Yrs

Middle Name Graduate? Y VAT No. Cell No.

Suburb Postal Code Postal Address:(If Different from Residential) Suburb Postal Code ) Previous Home Address:(Yrs Mnths Suburb Postal Code ) Employment Details: (Yrs Mnths Name Address Suburb Postal Code BusTelNo.( ) Fax No.( ) Type of Industry Employee No. EmpCont No.( ) Occupation ) Previous Employment Details:(Yrs Mnths Name Address Suburb Postal Code EmpCont No. ( ) Occupation Home Ownership: Y N Do you own your Property? (If Yes) In your name? In your Spouse's? Property Type: House Townhouse Erf Number Suburb Bond/Rental Payment per month: R , Bond Amount Outstanding: R , Purchase Price R Current Value R If a flexi/access bond, total facility granted? Bondholder Name Know Your Client (KYC ): Face to Face Off-Site R

Date Married / / (DD/MM/YY) ANC COP OTHER Spouse's Details: First Name Surname Income R Spouses ID No./ DOB Spouse Employer Name: Spouse Employers Address: Suburb Postal Code Relative's Details: (Nearest Relative in SA not living with you) Relationship Relative's Tel No.( ) Surname First Name Relative's Address: Suburb Postal Code Landlord's Details: (Name & Address of Landlord where goods will be kept) Landlord's Name: Landlord Address: Suburb Postal Code Banking Details: Account Type: Cheque Bank Name Account No. Account Holder Name (If appl) Overdraft Bal: R Credit Card Company Credit Card Number Cr.Facility Bal: Straight R Cr.Facility Limit: Straight R

Savings Transmission Branch Code

Limit: R

, ,

Budget R Budget R

, ,

Both? Flat

Existing &/or a previous Account with this Credit Provider: Branch No. Account No. Account Name Instalment Amount per month R , Number of Instalments Current? Paid up? To be settled? Existing accounts with other Credit Provider? Name of Company Account No Instalment Amount per month - R , Current? Paid up? To be settled? Name of Company Account No Instalment Amount per month - R , Current? Paid up? To be settled?

Face to Face On-Site Remote-Other

Individual Applicant

Sole Proprietor

Surety/Co-Debtor

ID/Passport No. Applicant's Income Details: Gross Remuneration Monthly Commission Car Allowance included in Gross Net Take-home Pay Income other than Salary/Wages Source of Income Total Monthly Income Applicant's Expenses per month: Bond Payment / Rent Rates, Water and Electricity Vehicle Instalments (excluding those to be settled) Personal Loan Repayments Credit Card Repayments Furniture Accounts Clothing Accounts Overdraft Repayments Policy/ Insurance Repayments Telephone Payment Transport Costs Food and Entertainment Education Costs Maintenance Household Expenses Other Total Monthly Expenses Applicant's Disposable Income / _ Date Remuneration Received: Are you currently liable as: Surety Specify Details:

Transaction Details: Goods Description Year Model Salesman Dealer Name Scheme Code M&M Code Special Requirements Balloon Payment % Residual Value % Purpose of Goods: Business Payment Frequency: Month Payment Mode: Advance Applicants Financial Details: Proposed Rate % Selling Price (VAT inclusive) Extras Description

Dealer Tel No. ( Buyline Code Period of Contract R R Private Bi-Ann Arrears , , Taxi Quart Cash

)
(Mnths)

R R R R R R R R R R R R R R R R R R R R R R R

, , , , , , , , , , , , , , , , , , , , , , ,

Commerce Annual DebitOrder

Total of Extras Dealer VAPS Description

Delivery Fee Initial Fuelling Charges License and Registration Costs Initiation Fees to be financed? Y Less Deposit /Initial Rental Source of Deposit Total Insurance-Bank VAPS InSale/Lease -Inside Act Credit Life Monthly Cover Plus Monthly Extended Warranty Other

Fixed R R R R R R R R R R R R N R R

Linked , , , , , , , , , , , , , ,

R , DD/MM/YY / Guarantor Co-debtor

Rental - Outside Act Credit Life Monthly Cover Plus Monthly Motor Comprehensive Monthly Courtesy Car Monthly Y N Policy No. Tel No. ( ) Annual Annual Annual Term Term Service & Maintenance Extended Warranty Other Term Term

Term

Comprehensive Vehicle Insurance? Existing Ins. Co Name

Broker Name

Monthly Annual Tel No. ( )

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 debt restructuring or alleviation. I do not have any current debt re-arrangement in existence. I have not previously applied for a debt 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.

If any of the above is incorrect, state which and give details: I. J. K. I would like to be included in any Telemarketing Campaign. I would like to be included in any Marketing List that you may sell or distribute I would like to be included in any mass distribution of emails or SMS messages. Y Y Y

N N N

I understand that I will be liable for a monthly service fee. I hereby consent to this Credit Provider making enquiries regarding my credit history with any credit bureau. 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 of Applicant

Date