Sales Representative -Select Sales Representative (Not Required)- Etienne Vermeulen Gustav Coetzee Jaco Vlok Jeff Montaqu Johan Wessels

Title ----- MR. MNR. MISS. MRS. MEV. MS. DR. PROF. PRINCE

Surname

Full Names

Cell Number

Email Address

Sex - Male Female

ID Number

No. Of Dependants

Are you married - Yes No

If you are married, how? - Single Married Divorced Widowed COP ANC

Date of Marriage (dd/mm/yyyy): DAY   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 DAY MONTH   1 2 3 4 5 6 7 8 9 10 11 12 YEAR   1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024

Home Address :

Street 1:

Street 2:

Street 3:

Suburb :

City :

Postal Code:

How long have you stayed at this address? (Years/Months):

Postal Address :

Postal Address:

P.O. Box 1 :

P.O. Box 2 :

P.O. Box 3 :

P.O. Box Suburb :

P.O. Box City :

P.O. Box Postal Code :

Telephone(Home):

Telephone(Work):

Spouse Name(if Married):

Spouse ID(if Married):

Spouse Cell Number(if Married):

Name:

Surname:

Cell Number:

Relationship - Friend Family Boss

Address:

Employers Company Name:

Managers Name:

Occupation?(What work do you do?):

How long have you worked there?:

Employers Address:

Employers Telephone:

What date do you get paid:

Who do you Bank With? - ABSA FNB Nedbank Standard Bank Capitec TYME BANK Other No Bank Details

Type of Account? - Cheque Transmission Savings

Bank Branch Name?:

Bank Account Number?

Bank Branch Number?

Name of Account Holder

Total Income Before Deductions

Total Income After Deductions

Total Expenses ie Rent, Vehicles, Food, Telephone, Electricity, etc

Bond Payment / Rent

Rates, Water, & Electricity

Vehicle Installments

Personal Loan Repayments

Credit Card Repayments

Furniture Accounts

Clothing Accounts

Overdraft Repayments

Insurance Repayments

Telephone Payment

Transport Costs

Food and Entertainment

Education Costs

Maintenance

Household Expenses

Other

I hereby give consent to the Credit Provider to make enquiries about my credit record with any of credit agencies and to obtain whatever information on me that they might require to process the credit application and / or application for insurance. I hereby declare that all of the above information is true and correct   I agree By ticking the confirmation tick box below you consent to all related parties for the collection and use of this information. *