Application Form
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Applicant details
First name
*
Middle name
Surname
*
ID/Passport number
*
Date of birth
*
YYYY slash MM slash DD
Vehicle details
Article type
Not Selected
Motor Vehicle
Light Duty Vehicle
MotorCycle
Boats
Caravans And Camping Equipment
OffRoad
Trailer
Jet-Ski
Article new/used
Not Selected
New
Used
Demo
Use of article
Not Selected
Private
Business
Taxi
Car Allowance
Company Car
Year model
Article make
Article description (model)
Article colour
Not Selected
White
Black
Red
Blue
Yellow
Silver
Green
Purple
Gold
Grey
Orange
M&M code (leave out if unknown)
Purchase price
Personal details
Preferred language
Not Selected
English
Afrikaans
Gender
Not Selected
Male
Female
Prefer not to say
Title
*
Not Selected
Advocate
Doctor
Mr
Miss
Mrs
Reverend
Professor
Race/Ethnic group
Not Selected
White
Coloured
Black
Asian
Indian
Country of nationality
Not Selected
South Africa
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Republic of North Macedonia
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland (the)
United States Minor Outlying Islands (the)
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ã…land Islands
Graduate
Not Selected
Yes
No
Marital status
Not Selected
Divorced
Married
Single
Widow/er
Separated
Matrimonial Property Act
Antenuptial Contract
Preferred contact method
Not Selected
Cell phone
Email
Home phone
Postal
Work phone
Mobile number
Mobile type
Not Selected
Pay As You Go
Contract
Phone number (H)
Phone Number (W) Type?
Not Selected
Land line
Cell
Email
*
Phone number (W)
Residential Details
Residential address line 1
Postal address (if different from residential address)
Not Selected
Use Address Below
Use Residential Address
Residential address line 2
Postal address line 1
Residential suburb
Postal Suburb
Residential city
Postal city
Postal code
Postal code
Owner/Tenant/Lodger
Not Selected
Bonded
Owner - Bond Free
Tenant
Lodger
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
MFC
MTN BANKING (Standard Bank)
NBS (Nedbank)
NEDBANK
NEDBANK (Lesotho)
NEDBANK (Namibia)
NEDBANK (Swaziland)
OTHER
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
Property current value
Period at current address (years)
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Period at current address (months)
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Period at previous address (years)
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Period at previous address (months)
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Employer details
Employer name (capture exactly as per payslip)
Ocupation
Not Selected
Able Seaman
Accommodation Occupations
Accountant/Auditor
Actor or Actress
Admin Assistant
Admin Clerk
Admin Manage
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
Boilermaker
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
Co-ordinator
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
Designer
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 Parttime
Farmer ie Grower
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
Graphic Designer
Grinder
Gynecologist
Hairdresser / Barber
Head of Technikon/College/School
Headmaster
Housekeeper
Housewife
IT/IT Technician
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
Safety Officer
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(Professional)
Self Employed(non-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
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
GOVERNMENT
MANUFACTURING
MEDICAL SERVICES - PRIVATE
MINING
NON-PROFIT ORGANISATIONS
PERSONAL SERVICES
RETAIL
TELKOM
TRANSPORT/STORAGE/COMMUNICATION
UNKNOWN
Employment type
Not Selected
Permanent
Contractual
Part time
Student
Self employed
Pensioner
Unemployed
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)
Self Employed(Professional)
Employer address line 1
Employer address line 2
Employer suburb
Employer city
Postal code
Company Year End
Not Selected
January
February
March
April
May
June
July
August
September
October
November
December
Period Employed (years)
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Period Employed (months)
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10
11
12
Period Previously Employed (years)
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Period Previously Employed (months)
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10
11
12
Income details
Source of income
*
Not Selected
Salary
Pension
Investments
Policy
Retirement Annuity
Donation/Gift
Inheritance
Self Employed
Gross remuneration
*
Monthly commission (included in gross)
Car allowance (included in gross)
Net take-home pay
*
Other income
TOTAL monthly income
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
Liability details
Surety
Yes
No
Surety description
Guarantor
Yes
No
Guarantor description
Co-debtor
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
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
Payment frequency
Not Selected
Monthly
Annually
Quarterly
Bi-Annually
Interest rate %
Rate indicator
Not Selected
Linked
Fixed
Residual/Balloon value percentage
Deposit
Finance initiation fees
Not Selected
Yes
No
Pay in advance
Not Selected
Yes
No
Relative Details
First name (Relative)
Surname (Relative)
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
Preferred contact method
Not Selected
Cellphone
Home
Work
Phone number
Relative address line 1
Relative address line 2
Suburb
City
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)
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
OTHER
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
Account number 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
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
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Consent
Do you consent to your information being shared to receive marketing regarding insurance and related products?
Not Selected
Yes
No
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
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
Name
This field is for validation purposes and should be left unchanged.