System Message
E-Application Form
First Name
Middle Name
Surname
ID Number
Date of Birth (CCYYMMDD)
Vehicle Details
Article Type
Motor Vehicle
Light Duty Vehicle
MotorCycle
Boats
Caravans And Camping Equipment
Engine
Heavy Commercial
Medium Commercial
Agricultural
Unknown
Bus
Trailer
Jet-Ski
OffRoad
Microbus/Taxi
Quad Bikes
Sea/Water Transport Equipment
Article New/Used
New
Used
Demo
Use of Article
Private
Business
Taxi
Car Allowance
Company Car
Year Model
Article Make
Article Description
M&M Code
Purchase Price
Article Colour
Not Selected
White
Black
Red
Blue
Yellow
Silver
Green
Purple
Gold
Grey
Orange
Personal Details
Preferred Language
Not Selected
Afrikaans
English
Zulu
Tswana
Xhosa
South Sotho
IsiNdebele
NorthernSotho
SiSwati
Tshivenda
Xitsonga
Gender
Not Selected
Male
Female
Title
Not Selected
Advocate
Doctor
Mr
Professor
Reverend
Miss
Mrs
Unknown
Ms
SIR
Messrs
Mr and Mrs
Attorney
Sister
Major
Commandant
Colonel
Brigadier
General
Captain
Race/Ethnic Group
Not Selected
White
Coloured
Black
Asian
Indian
Country of Nationality
Not Selected
SOUTH AFRICA
AFGANISTAN
ALBANIA
ALGERIA
AMERICAN SAMOA
ANDORRA
ANGOLA
ANTIGUA (WEST INDIES)
ARGENTINA
AUSTRALIA
AUSTRIA
AZORES
BAHAMAS
BAHRAIN
BANGLADESH
BARBADOS
BELEARIC ISLAND (SPAIN)
BELGIUM
BELIZE
BENIN
BERMUDA
BHUTAN
BOLIVIA
BOTSWANA
BRAZIL
BRUNEI
BULGARIA
BURUNDI
CAMEROON (UNITED REPUBLIC OF)
CANADA
CAPE VERDE
CAYMAN ISLAND (WEST INDIES)
CENTRAL AFRICAN REPUBLIC
CHAD
CHILE
CHINA
CHRISTMAS ISLAND
COCOS (KEELING) ISLAND
COLUMBIA
COMOROS
CONGO (PEOPLE DEMOCRATIC REPUBLIC OF)
COOK ISLAND
COSTA RICA
CUBA
CYPRUS
DENMARK
DJIBOUTI
DOMINICA (WEST INDIES)
DOMINICAN REPUBLIC
EAST TIMOR
ECUADOR
EGYPT
EL SALVADOR
EQUATORIAL GUINEA
ETHIOPIA
FALKLAND ISLAND
FEAROE ISLAND
FIJI
FINLAND
FRANCE
FRENCH GUIANA
FRENCH POLYNESIA
GABON
GAMBIA
GERMANY (DEMOCRATIC)
GHANA
GIBRALTAR
GRANADA (WEST INDIES)
GREECE
GREENLAND
GUADELOUPE (MARIE-GALANTE AND ST BARTHELEM)
GUAM
GUATEMALA
GUINEA
GUINEA-BISSAU
GUYANA
HAITI
HONDURAS
HONG KONG
HUNGARY
ICELAND
INDIA
INDONESIA
IRAN
IRAQ
IRELAND
ISRAEL
ITALY
JAMAICA
JAPAN
JORDAN
KENYA
KIRIBATI
KOREA (NORTH DEMOCRATIC PEOPLE REPUBLIC)
KOREA (SOUTH DEMOCRATIC PEOPLE REPUBLIC)
KUWAIT
LAO (PEOPLE DEMOCRATIC REPUBLIC)
LEBANON
LESOTHO
LIBERIA
LIBYA
LIECHTENSTEIN
LUXEMBORG
MACAU
MADAGASCAR
MALAWI (REPUBLIC OF)
MALAYSIA
MALDIVES
MALI (REPUBLIC OF)
MALTA-GOZO
MARTINIQUE (FRENCH WEST INDIES)
MAURITANIA
MAURITIUS
MEXICO
MONACO
MONGOLIA
MONTSERRAT (WEST INDIES)
MOROCCO
MOZAMBIQUE
NAMIBIA
NAURU ISLAND
NEPAL
NETHERLANDS
NETHERLANDS ANTILLES
NEW CALEDONIA
NEW ZEALAND
NICARAGUA
NIGER
NIGERIA
NIUE ISLAND
NORFOLK ISLAND
NORWAY
OMAN
PAKISTAN
PALAU ISLANDS
PANAMA
PAPUA NEW GUINEA
PARAGUAY
PERU
PHILLIPINES
POLAND
PORTUGAL
PUERTO RICO
QATAR
REUNION
ROMANIA
RWANDA
SAMOA
SAN MARINO
SAO TOME AND PRINCIPE
SAUDI ARABIA
SENEGAL
SEYCHELLES
SIERRA LEONNE
SINGAPORE
SOLOMON ISLANDS
SOMALIA
SPAIN
SRI LANKA (CEYLON)
ST HELENA
ST KITTS-NEVAS ANGUILLA
ST LUCIA
SURINAM REPUBLIC
ESWATINI
SWEDEN
SWITZERLAND
SYRIAN ARAB REPUBLIC
TAIWAN
TANZANIA (UNITED REPUBLIC OF)
THAILAND
TOGO (REPUBLIC OF)
TOKELAU ISLANDS
TONGA
TRINIDAD AND TOBAGO
TUNISIA
TURKEY
TURKS AND CAICOS ISLANDS
TUVALU ISLANDS
UGANDA
UKRAINE
UNITED ARAB EMIRATES
UNITED KINGDOM
UNITED STATES VIRGIN ISLANDS
URUGUAY
USA
VANUATU ISLAND
VENEZUELA
VIETNAM
WALLIS FUTUNA ISLANDS
WESTERN SAHARA
YEMEN
ZAMBIA
ZIMBABWE
ANGUILLA
ARMENIA
ANTARCTICA
ARUBA
ALAND ISLAND
AZERBAIJAN
BOSNIA AND HERZEGOVINA
BURNKINA FASO
BONAIRE
BOUVET ISLAND
BELARUS
CONGO, THE DEMOCRATIC REPUBLIC OF THE CONGO
COTE D_IVOIRE
CURACAO
ESTONIA
ERITREA
MICRONESIA (FEDERATED STATES OF)
GEORGIA
GUERNSEY
SOUTH GEORGIA AND SOUTH SANDWICH ISLANDS
HEARD ISLAND AND MC DONALD ISLANDS
CROATIA
ISLE OF MAN
BRITISH INDIAN OCEAN TERRITORY
JERSEY
KYRGYZSTAN
CAMBODIA
KAZAKSTAN
LITHUANIA
LATVIA
MOLDOVA, REPUBLIC OF
MONTENEGRO, REPULIC OF
MARSHALL ISLANDS
MACEDONIA,THE FORMER YUGOSLAV REPUBLIC OF
MYANMAR
NORTHERN MARIANA ISLANDS
SAINT PIERRE & MIQUELON
PITCAIRN
PALESTINIAN TERRITORY, OCCUPIED
SERBIA, REPUBLIC OF
RUSSIAN FEDERATION
SUDAN
SLOVENIA
SVALBARD & JAN MAYEN
SLOVAKIA
SOUTH SUDAN
TURKS & CAICOS ISLANDS
FRENCH SOUTHERN TERRITORIES
TAJIKISTAN
TIMOR LESTE
TURKMENISTAN
UNITED STATES MINOR OUTLYING ISLANDS
UZBEKISTAN
HOLY SEE (VATICAN CITY STATE)
SAINT VINCENT & THE GRENADINES
VIRGIN ISLANDS (BRITISH)
KOSOVO
MAYOTTE
COUNTRY UNKNOWN
CZECH REPUBLIC
FEDERAL REPUBLIC OF YUGOSLAVIA
KOREA
KOREA (REPUBLIC OF)
SAINT KITTS AND NEVIS
Graduate
Not Selected
Yes
No
Marital Status
Not Selected
Divorced
Married
Single
Widow/er
Separated
Matrimonial Property Act
Antenuptial Contract
Marital Contract
Not Selected
Antenuptual Contract
In Community of property
Tribal
Married in COP (Chapter 2 & 3)
Married in COP ( not Chapter 2 & 3)
Foreign/Custom
Antenuptual Contract excl. Accrual
Antenuptual Contract incl. Accrual
Muslim or Hindu rites
Date Married (CCYYMMDD)
Preferred Contact Method
Cell phone
Home phone
Work phone
Email
Postal
All
Telephone
SMS
None
Mobile Number
Mobile Type
Not Selected
Pay as you go
Contract
Phone Number (H)
Is Work Phone Number A Cell
Not Selected
Yes
No
E-Mail Address
Phone Number (W)
Residential Details
Residential Address 1
Postal Address
Not Selected
Use Address Below
Use Residential Address
Residential Address 2
Postal Address Line 1
Residential City
Postal City
Residential Suburb
Postal Suburb
Postal Code
Postal Code
Owner/Tenant/Lodger
Not Selected
Owner - Bonded
Owner - Bond Free
Tenant
Lodger
Living With Parents
Outstanding Bond Balance
Bonded via
Not Selected
ABN AMRO BANK
ABSA BANK
AFRICAN BANK
BANK WINDHOEK
BIDVEST BANK
BOE BANK (NEDBANK)
CAPITEC BANK
CITIBANK
FBC FIDELITY BANK LTD
FIRST NATIONAL BANK
GRINDROD BANK
HABIB OVERSEAS BANK
HBZ BANK
INVESTEC BANK LIMITED
MERCANTILE BANK
MTN BANKING (Standard Bank)
NBS (Nedbank)
NEDBANK
NEDBANK (Lesotho)
NEDBANK (Namibia)
NEDBANK (Swaziland)
PEP BANK (NEDBANK)
PERMANENT BANK
RESERVE BANK
SA BANK OF ATHENS
SA POST OFFICE
STANDARD BANK
STANDARD BANK (SWAZILAND)
STANDARD CHARTERED BANK (20TWENTY)
STANDARD LESOTHO BANK LIMITED
UBAN BANK
Wesbank
MFC
OTHER
Property Current Value
Period at Address (YY MM)
Period at
Previous
Address (YYMM)
Do you share liability for a homeloan with another person?
African Bank
Not Selected
Yes
No
Passport Details
Passport Issue Date (CCYYMMDD)
Passport Expiry Date (CCYYMMDD)
Permit Type
Not Selected
Asylum Seeker
Permanent Resident
Refugee
Study Permit
Work Permit
Temporary Resident
Permit Number
Permit Country of Issue
Not Selected
SOUTH AFRICA
AFGANISTAN
ALBANIA
ALGERIA
AMERICAN SAMOA
ANDORRA
ANGOLA
ANTIGUA (WEST INDIES)
ARGENTINA
AUSTRALIA
AUSTRIA
AZORES
BAHAMAS
BAHRAIN
BANGLADESH
BARBADOS
BELEARIC ISLAND (SPAIN)
BELGIUM
BELIZE
BENIN
BERMUDA
BHUTAN
BOLIVIA
BOTSWANA
BRAZIL
BRUNEI
BULGARIA
BURUNDI
CAMEROON (UNITED REPUBLIC OF)
CANADA
CAPE VERDE
CAYMAN ISLAND (WEST INDIES)
CENTRAL AFRICAN REPUBLIC
CHAD
CHILE
CHINA
CHRISTMAS ISLAND
COCOS (KEELING) ISLAND
COLUMBIA
COMOROS
CONGO (PEOPLE DEMOCRATIC REPUBLIC OF)
COOK ISLAND
COSTA RICA
CUBA
CYPRUS
DENMARK
DJIBOUTI
DOMINICA (WEST INDIES)
DOMINICAN REPUBLIC
EAST TIMOR
ECUADOR
EGYPT
EL SALVADOR
EQUATORIAL GUINEA
ETHIOPIA
FALKLAND ISLAND
FEAROE ISLAND
FIJI
FINLAND
FRANCE
FRENCH GUIANA
FRENCH POLYNESIA
GABON
GAMBIA
GERMANY (DEMOCRATIC)
GHANA
GIBRALTAR
GRANADA (WEST INDIES)
GREECE
GREENLAND
GUADELOUPE (MARIE-GALANTE AND ST BARTHELEM)
GUAM
GUATEMALA
GUINEA
GUINEA-BISSAU
GUYANA
HAITI
HONDURAS
HONG KONG
HUNGARY
ICELAND
INDIA
INDONESIA
IRAN
IRAQ
IRELAND
ISRAEL
ITALY
JAMAICA
JAPAN
JORDAN
KENYA
KIRIBATI
KOREA (NORTH DEMOCRATIC PEOPLE REPUBLIC)
KOREA (SOUTH DEMOCRATIC PEOPLE REPUBLIC)
KUWAIT
LAO (PEOPLE DEMOCRATIC REPUBLIC)
LEBANON
LESOTHO
LIBERIA
LIBYA
LIECHTENSTEIN
LUXEMBORG
MACAU
MADAGASCAR
MALAWI (REPUBLIC OF)
MALAYSIA
MALDIVES
MALI (REPUBLIC OF)
MALTA-GOZO
MARTINIQUE (FRENCH WEST INDIES)
MAURITANIA
MAURITIUS
MEXICO
MONACO
MONGOLIA
MONTSERRAT (WEST INDIES)
MOROCCO
MOZAMBIQUE
NAMIBIA
NAURU ISLAND
NEPAL
NETHERLANDS
NETHERLANDS ANTILLES
NEW CALEDONIA
NEW ZEALAND
NICARAGUA
NIGER
NIGERIA
NIUE ISLAND
NORFOLK ISLAND
NORWAY
OMAN
PAKISTAN
PALAU ISLANDS
PANAMA
PAPUA NEW GUINEA
PARAGUAY
PERU
PHILLIPINES
POLAND
PORTUGAL
PUERTO RICO
QATAR
REUNION
ROMANIA
RWANDA
SAMOA
SAN MARINO
SAO TOME AND PRINCIPE
SAUDI ARABIA
SENEGAL
SEYCHELLES
SIERRA LEONNE
SINGAPORE
SOLOMON ISLANDS
SOMALIA
SPAIN
SRI LANKA (CEYLON)
ST HELENA
ST KITTS-NEVAS ANGUILLA
ST LUCIA
SURINAM REPUBLIC
ESWATINI
SWEDEN
SWITZERLAND
SYRIAN ARAB REPUBLIC
TAIWAN
TANZANIA (UNITED REPUBLIC OF)
THAILAND
TOGO (REPUBLIC OF)
TOKELAU ISLANDS
TONGA
TRINIDAD AND TOBAGO
TUNISIA
TURKEY
TURKS AND CAICOS ISLANDS
TUVALU ISLANDS
UGANDA
UKRAINE
UNITED ARAB EMIRATES
UNITED KINGDOM
UNITED STATES VIRGIN ISLANDS
URUGUAY
USA
VANUATU ISLAND
VENEZUELA
VIETNAM
WALLIS FUTUNA ISLANDS
WESTERN SAHARA
YEMEN
ZAMBIA
ZIMBABWE
Czech Republic
SLOVAKIA
CROATIA
Permit Issue Date (CCYYMMDD)
Permit Expiry Date (CCYYMMDD)
Work Contract Expiry Date (CCYYMMDD)
Spouse Details
First Name
Middle Name
Surname
Identification Type
South African Valid ID
Passport
ID Number
Date of Birth (CCYYMMDD)
Mobile Number
Employer Details
Employer Name (Please capture exactly as per payslip)
Occupation
Not Selected
Able Seaman
Accommodation Occupations
Accountant/Auditor
Actor or Actress
Admin Assistant
Admin Clerk
Admin Manager
Admiral
Advocate
Air Transport Occupations
Ammunition Seeker
Anaesthetist
Appraiser
Apprentice
Architect
Area Manager
Artisan
Artist
Assembler
Assessor
Assistant
Assistant Manager
Assistant to the Trades
Attorney
Auctioneer
Author
Baker
Bank Employee
Bank Teller
Barmaid
Barman / Bartender
Beautician
Biologist
Bombardier
Book Maker
Bookkeeper
Bricklayer
Brigadier
Broker
Builder
Building Contractor
Building Inspector
Building Painter
Business Consultant
Butcher
Buyer
Cabinet Maker
Cabinet Minister
Cable Joiner
Candidate Officer
Captain
Carpenter / Joiner
Carpenter or Joiner
Cashier
Casting Worker
Catering Occupations
Chairman of Company
Chartered Accountant
Chefs
Chemist
Chief Petty Officer
Chiropracter
Civil Servant
Colonel
Commander
Commandore
Commissioner
Computer Operator
Computer Programmer
Computer System Analyst
Constable
Consultants
Cook
Copywriter
Corporal
Credit Collector or Personnel
Dance Instructor
Data Puncher
Dean
Debtors / Creditors Clerk
Dental Assistant
Dentist
Diplomat - not RSA Citizen
Director
District Manager
Doctor / General Practitioner
Draughtsman
Driver - Vehicle
Electrician
Engineer
Ensign
Estate Agent
Extension Officer - Agricultural
Factory Worker
Farm Foreman
Farm Worker
Farmer (Private Capacity)
Farmer ie Grower
Farmer Parttime
Financial Advisors
Fireman
Fisherman or Hunter
Fisherman/Hunter
Fitter And Turner
Flight Sargeant
Foreman
Forensic Analyst
Foundry Worker
Funeral Director
General
General Manager - Company
Geologist
Glazier
Government Employees
Grinder
Gynecologist
Hairdresser / Barber
Head of Technikon/College/School
Headmaster
Housekeeper
Housewife
Inspector
Inspector of Schools
Insurance Agent
Insurance Broker
Insurance Consultant
Interior Decorator
Iron Worker
Jeweller
Journalist
Judge
Labourer / Unskilled Labourer
Labourer or Unskilled Labourer
Laundryman
Lay preacher
Leading Seaman
Lecturer
Legal Professions Other
Librarian
Lieutenant
Lieutenant Colonel
Lieutenant Commander
Lieutenant General
Lumberman
Machine Operator
Machinist
Major
Major General
Manager
Managing Director
Market Checker
Mason
Mechanic
Medic
Medical Doctor
Member of Parliament
Member of Provincial Council
Metal Worker
Meter Reader
Midshipman
Millwright
Mine Worker
Minister
Missionary
Model
Moulder
Municipal Servant
Musician
Nurse
Nursery Worker
Nursing Sister
Office Worker
Officer
Operator/Production Worker
Optician
Other Occupations Not Mentioned
Packer
Painter
Painter - Buildings
Paramedics
Part time / Contract Worker
Pensioner
Personnel Occupations
Petty Officer
Pharmacist
Photographer
Pilot
Pipefitter
Plasterer
Plumber
Police Officer
Porter
Postal Services Occupations
President
Priest
Prison Officer
Private
Production Control
Production Line Worker
Professor
Prospector
Psychiatrist
Psychologist
Quality Control
Quality Surveyor
Radio Announcer
Rail Transport Occupation
Rear Admiral
Receptionist
Rector
Regional Manager
Repair Man
Reporter
Researchers
Retired
Rigger / Scaffolder
Road Transport Occupations
Salesman
Salesman/Marketer
Sargeant
Sargeant Major
Scholar
Scientist
Sculptor
Sea Transport Occupations
Seaman
Second Bombardier
Second Corporal
Second Lieutenant
Secretary
Security Guard
Security Officer
Self Employed(non-professional)
Self Employed(Professional)
Senator
Senior Executive Consultant
Senior Superintendent
Serviceman
Shopfitter
Singer
Slaughterman
Social Worker
Soldier
Sole Owner
Sole Owner - Individual(retail bank)
Sole Owner(Business Bank)
Specialist
Sport Occupations
Spray Painter
Staff Sargeant
Stage Artist
Steel Worker
Steeplejack
Stock Controller
Student
Sub-Lieutenant
Superintendent
Supervisor
Surgeon
Surveyor
Taxi Owner / Driver
Teacher
Technician
Telecommunication Occupation
Telephonist
Therapeutist
Traffic Officer
Train Driver
Transport Contractor
Typist
Unemployed
Veterinarian
Vice Admiral
Vice Corporal
Waiter
Warrent Officer
Welder
Zoologist
Analyst
Boilermaker
Co-ordinator
Designer
Graphic Designer
IT/IT Technician
Logistics
Merchandiser
Protective Services
Education
Self Employed
Auditor
Accountant
Artisans and Related
Quantity Surveyor
Safety Officer
Executive
Academical
Actuary
Agricultural And Related Occupations
Airline Cabin Staff
Articled Clerk
Arts & Entertainment And Related Occupations
Bank Clerk
Bookmaker
Building And Related Occupations
Casher
Chairman(Exec)
Chartered Accntnt
Chemical Engineer
Civil Servant - Managerial
Civil Srvnt-Clerck
Clerical
Co Secrtry(Exec)
Controller
Credit Controller
Customs Officer
Diamond Digger
Diamond Sorter
Director(Exec)
Doctor
Electrician & Related Occupations
Fabrication & Repair Of Stone, Sand, Clay
Fabrication And Repair Of Wood & Wood Products And Related Occupations
Financial Advisor
Fishery & Related Occupations
Food, Beverage Preparation & Related Occupations
Forestry & Related Occupations
Game Ranger
General Manager (Exec)
General Manager (Non-Exec)
Hair & Beauty And Related Occupations
Income Tax Inspector
Internal Medicine
Jockey
Lawyer
Lodging & Related Occupations
Magistrate
Managerial
Managing Dir(Exec)
Mechanics & Machinery Repairers
Medical Specialist
Member Of Parlement
Metal Mining, Fabricating And Related Occupations
Mining Engineer
Minister Of Relgn
Minister(Gov)
Painting & Decorating And Related Occupations
Personnel Officer
Plumber & Related Occupations
Postal Service Occupations
Prof/Graduate Self Employed
Public Prosecutor
Salesperson & Related Occupations
Sports Professional
Tax Consultant
Teller
Textile Occupations
Trader
Transportation And Related Occupations
Welders & Cutters And Related Occupations
Departmental Head (At Schools)
Game Ranger
Field Ranger
Office worker
IT Consultant
Business Analyst
Software developer
Developer
Call centre agent
Key Account Manager
Project Manager
Product Manager/Owner
Test Analyst
Senior Manager
Winemaker
Employer Industry Type
Not Selected
AGRICULTURE
BUILDING AND CONSTRUCTION
BUSINESS SERVICES
COMMERCE
COMMUNITY SERVICE
EDUCATIONAL SERVICES - PRIVATE
ELECTRICITY,GAS AND WATER
ENTERTAINMENT/SPORTS/RECREATION
ESCOM
FINANCIAL SERVICES
GOVERNMENT
MANUFACTURING
MEDICAL SERVICES - PRIVATE
MINING
NON-PROFIT ORGANISATIONS
PERSONAL SERVICES
TELKOM
TRANSPORT/STORAGE/COMMUNICATION
UNKNOWN
ADVERTISING AGENTS
ARCHITECTS/LAND/QUANT
AUTOMOTIVE DEALERS
CUSTOM, FORWARDING & SHIPPING AGENTS
DIAMOND JEWELLERS INDUSTRY
ELECTRONIC AND POWER GENERATION EQUIPMENT
ELECTRONIC EQUIPMENT
ENGINEERING
INSURANCE SERVICES
FISHING INDUSTRY
FUR BEARING ANIMALS AND RABBIT FARMING
HUNTING TRAPPING GAME PROPAGATION
LEGAL OCCUPATION AND SERVICES
MANUFACTURING AND DISTRIBUTION
MANUFACTURING AUTO REPAIR & OTHER REPAIR SERVICES
MANUFACTURING CHEMICAL & RELATED PRODUCTS
MANUFACTURING EQUIPMENT & INSTRUMENTS
MANUFACTURING FOOD & KINDRED PRODUCTS
MANUFACTURING FURNITURE & WOOD PRODUCTS
MANUFACTURING METAL & METAL PRODUCTS
MANUFACTURING PAPER & PRINTING PRODUCTS
MANUFACTURING PAPER A& ALLIED PRODUCTS
MANUFACTURING RUBBER & PLASTIC PRODUCTS
MANUFACTURING STONE CLAY & GLASS PRODUCTS
MANUFACTURING TEXTILE PRODUCTS
MISCELLANEOUS RETAIL
PROPERTY AND RELATED SERVICES
REAL ESTATE
RETAIL
SPECIALISED AGRICULTURE
TOBACCO MANUFACTURING AND SALES
TRANSPORT INDUSTRY
TRANSPORT OTHER THAN ROAD
VETERINARY SERVICES
INFORMATION TECHNOLOGY
PROTECTIVE SERVICES INCL. POLICE, ARMED FORCES
AGRICULTURE,FORESTRY & FISHING
ACCOMMODATION & CATERING
MANUFACTURING MOTOR INDUSTRY COMPONENTS
CRUDE PETROLEUM AND NATURAL GAS
INSURANCE AGENTS, BROKERS, & SERVICE
DISTRIBUTION-SUPERMARKETS
PRINTING, PUBLISHING AND EDITORIAL
APPAREL AND OTHER TEXTILE PRODUCTS
DISTRIBUTION-JEWELLERS
REPAIR SERVICES
RETIRED
Employment Type
Not Selected
Permanent
Contractual
Part time
Student
Self employed
Pensioner
Unemployed
Company
Full Time
UNKNOWN
Employment Level
Not Selected
Senior Management
Management
Supervisor
Skilled Worker
Semi-Skilled Worker
Unskilled Worker
Junior Position
Client Type
Not Selected
Private Individual
Self employed(non-professional) - Sole Proprietor
Self employed(non-professional) - Farmer
Self employed(professional) - Sole Proprietor
Self employed(professional) - Farmer
Self Employed(Non-professional)
Self Employed(Professional)
Sole Proprietor
Employer Address Line 1
Employer Address Line 2
Employer City
Company Year End:
Not Selected
January
February
March
April
May
June
July
August
September
October
November
December
Employer Suburb
Postal Code
Period Employed (YY MM)
Period
Previously
Employed (YY MM)
Are you a government employee?
African Bank
Not Selected
Yes
No
Applicant Income Details
Source of income
Not Selected
Salary
Pension
Investments
Policy
Retirement Annuity
Donation/Gift
Inheritance
Self Employed
Gross Remuneration
Monthly Commission (Inc in Gross)
Car allowance (Inc in Gross)
Net Take-home Pay
Other Income
TOTAL
Monthly Income
Spouse/Other Income Details
Gross Remuneration
Monthly Commission (Inc in Gross)
Car allowance (Inc in Gross)
Net Take-home Pay
Other Income
TOTAL
Monthly Income
Expenses
Applicant Expenses
Spouse Expenses
Bond Payment
Bond Payment
Rent
Rent
Bond Payment/Rent Total
Bond Payment/Rent Total
Rates, Water & Electricity
Rates, Water & Electricity
Vehicle Instalments (Excluding Instalments to be settled)
Vehicle Instalments (Excluding Instalments to be settled)
Personal Loan Repayments
Personal Loan Repayments
Credit Card Repayments
Credit Card Repayments
Furniture Accounts
Furniture Accounts
Clothing Accounts
Clothing Accounts
Overdraft Repayments
Overdraft Repayments
Policy/Insurance Payments
Policy/Insurance Payments
Telephone Payments
Telephone Payments
Transport Costs
Transport Costs
Food and Entertainment
Food and Entertainment
Education Costs
Education Costs
Maintenance
Maintenance
Household Expenses
Household Expenses
Other Expenses
Other Expenses
Loans repaid via payroll deduction
Loans repaid via payroll deduction
TOTAL
Expenses
TOTAL
Expenses
Disposable Income
Disposable Income
Other Income
Wage Frequency
Not Selected
Monthly
Weekly
Fortnightly
Annually
Quarterly
Bi-Annually
Wage Frequency
Not Selected
Monthly
Weekly
Fortnightly
Pay Day
Not Selected
1
2
3
4
5
6
7
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9
10
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25
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27
28
29
30
31
Pay Day
Not Selected
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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24
25
26
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28
29
30
31
Bonus
Bonus
Other Non-Recurring Income
Other Non-Recurring Income
Liability Details
Surety
Not Selected
Yes
No
Surety Description
Guarantor
Not Selected
Yes
No
Guarantor Description
Co-Debtor
Not Selected
Yes
No
Co-Debtor Description
Payment History
Are You Currently Under Debt-Review?
Not selected
Yes
No
Do you have a re-arrangement in place with any credit provider as a result of debt Counselling?
Not selected
Yes
No
Are you currently under administration order or Curator Bonus?
Not selected
Yes
No
Have you ever been under administration order?
Not selected
Yes
No
Have you ever had a judgment against you to your knowledge?
Not selected
Yes
No
Do you have a dispute in progress with a credit bureau?
Not selected
Yes
No
Are you currently under sequestration order?
Not selected
Yes
No
Finance Details
Agreement
Not Selected
Installment Sale Agreement
Lease Agreement
Buy-Back
Repayment Period
Not Selected
6 Months
12 Months
18 Months
24 Months
30 Months
36 Months
42 Months
48 Months
54 Months
60 Months
72 Months
78 Months
84 Months
96 Months
66 months
90 months
Payment Frequency
Not Selected
Monthly
Annually
Quarterly
Bi-Annually
Interest Rate: %
Rate Indicator
Not Selected
Linked
Fixed
Residual / Balloon Value: %
Deposit
Finance Initiation Fees
Not Selected
Yes
No
Pay in Advance
Not Selected
Yes
No
Take A Break Month
Wesbank
Not Selected
January
February
March
April
May
June
July
August
September
October
November
December
Relative Details
First Name
Surname
Relation
Not Selected
Aunt
Brother
Brother in Law
Cousin
Daughter
Father
Father in Law
Friend
Grandfather
Grandmother
Husband
Mother
Mother in Law
Sister
Sister in Law
Son
Uncle
Wife
Relative
Preferred Contact Method
Not Selected
Cellphone
Home
Work
Contact Number
Relative Address 1
Relative Address 2
Relative City
Relative Suburb
Postal Code
Banking Details
Bank Name
Not Selected
ABN AMRO BANK
ABSA BANK
AFRICAN BANK
BANK WINDHOEK
BIDVEST BANK
BOE BANK (NEDBANK)
CAPITEC BANK
CITIBANK
FBC FIDELITY BANK LTD
FIRST NATIONAL BANK
GRINDROD BANK
HABIB OVERSEAS BANK
HBZ BANK
INVESTEC BANK LIMITED
ITHALA (ABSA)
MERCANTILE BANK
NBS (NEDBANK)
NEDBANK
NEDBANK (Lesotho)
NEDBANK (Namibia)
NEDBANK (Swaziland)
OTHER
PEP BANK (NEDBANK)
RESERVE BANK
SA BANK OF ATHENS
SA POST OFFICE
STANDARD BANK
STANDARD BANK (SWAZILAND)
STANDARD CHARTERED BANK (20TWENTY)
STANDARD LESOTHO BANK LIMITED
TEBA BANK
TOYOTA FINANCIAL SERVICES
UNIBANK LIMITED
WESBANK
AL BARAKA
Alphera Finance
BANK OF ATHENS
BMW FINANCE
RAND MERCHANT BANK
VOLKSWAGEN FINANCIAL SERVICES
AUDI FINANCIAL SERVICES
MERCEDES BENZ FINANCE
DISCOVERY BANK
TYMEBANK
OLD MUTUAL BANK
PERMANENT BANK
ACCESS BANK
Bank Branch
Account Holder (Same as Applicant)
Account Number
Account Type
Not Selected
Cheque
Savings
Transmission
Credit Card
Branch Code
Settle existing Instalment
Not Selected
Yes
No
Payment Method
Not Selected
Cash
Debit Order
Self Invoice
Bank
Debit Order 50% Cash 50%
Debit Order 60% Cash 40%
Debit Order 70% Cash 30%
Debit Order 80% Cash 20%
Debit Order 90% Cash 10%
Account No. to settle
Bank Name (Account to be settled)
Not Selected
ABN AMRO BANK
ABSA BANK
AFRICAN BANK
BANK WINDHOEK
BIDVEST BANK
BOE BANK (NEDBANK)
CAPITEC BANK
CITIBANK
FBC FIDELITY BANK LTD
FIRST NATIONAL BANK
GRINDROD BANK
HABIB OVERSEAS BANK
HBZ BANK
INVESTEC BANK LIMITED
MERCANTILE BANK
MTN BANKING (Standard Bank)
NBS (Nedbank)
NEDBANK
NEDBANK (Lesotho)
NEDBANK (Namibia)
NEDBANK (Swaziland)
PEP BANK (NEDBANK)
PERMANENT BANK
RESERVE BANK
SA BANK OF ATHENS
SA POST OFFICE
STANDARD BANK
STANDARD BANK (SWAZILAND)
STANDARD CHARTERED BANK (20TWENTY)
STANDARD LESOTHO BANK LIMITED
UBAN BANK
Wesbank
MFC
OTHER
Monthly Instalment (Account to be settled)
Settlement Amount
Payment Date
01
02
03
04
05
06
07
08
09
10
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14
15
16
17
18
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20
21
22
23
24
25
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27
28
29
30
31
Salary paid into this account?
African Bank
Not Selected
Yes
No
Application Details
Do you consent to your information being shared in order to receive marketing regarding insurance and related products?
Not Selected
Yes
No
I hereby consent to the Credit Provider accessing my credit profile from the credit bureaus for the purposes of a credit assessment and in the event that my loan application is successful, for on-going account maintenance purposes, setting limits, development of credit tools/products/models and insurance purposes.
Not Selected
Yes
No
In order to provide outstanding service to you, we would like your consent to share your details within the Alphera Group Companies and dealerships. Do you give your consent?
Not Selected
Yes
No
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