Finance Application

Client No. Application Number Application Date

By completing and submitting this application, the applicant confirms 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 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.
	I hereby declare that the information provided by me is true and correct.
We will not disclose any personal information to any party.
I would like to be included in any Telemarketing Campaign.		Y		N
I would like to be included in any Marketing List that you may sell or distribute.		Y		N
I would like to be included in any mass distribution of emails or SMS messages.		Y		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 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 __________________________