Individual Old

First name

Middle name

Surname

ID number

Date of birth

Preferred language

Gender

Title

Race/Ethnic group

Country of nationality

Graduate

Marital status

Preferred contact method

Mobile number

Mobile type

Phone number (H)

Is work phone number a cell

Postal code

Residential address 1

Postal Address

Residential Address 2

Postal Address Line 1

Residential City

Postal City

Residential Suburb

Postal Suburb

Postal Code

Owner/Tenant/Lodger

Outstanding bond balance

Bonded via

Period at previous

Employer name (capture exactly as per payslip)

Occupation

Employer industry type

Employment type

Employment Level

Client Type

Employer Address Line 1

Employer Address Line 2

Employer City

Company year end

Employer Suburb

Postal Code

Period employed (YY MM)

Period previously employed (YY MM)

Source of income

Gross remuneration

Monthly commission (included in gross)

Car allowance (included in gross)

Net take-home pay

Other income

Bond payment

Rent

Bond payment/Rent total

Rates, water & electricity

Vehicle instalments (excluding instalments to be settled)

Furniture accounts

Clothing accounts

Overdraft repayments

Policy/Insurance payments

Telephone payments

Transport costs

Food and entertainment

Education costs

Maintenance

Household expenses

Other expenses

Loans repaid via payroll deduction

TOTAL expenses

Disposable income

Surety

Surety description

Guarantor

Guarantor description

Co-debtor

Co-debtor description

Are you currently under debt-review?

Do you have a re-arrangement in place with any credit provider as a result of debt Counselling?

Are you currently under administration order or Curator Bonus?

Have you ever been under administration order?

Have you ever had a judgment against you to your knowledge?

Do you have a dispute in progress with a credit bureau?

Are you currently under sequestration order?

Agreement

Repayment period

Payment frequency

Interest rate: %

Rate indicator

Residual/Balloon value %

Deposit

Finance initiation Fees

Pay in advance

First name

Surname

Preferred contact method

Contact number

Relative Address 1

Relative Address 2

Relative City

Relative Suburb

Postal Code

Bank Name

Bank Branch

Account Holder (Same as Applicant)

Account Number

Account Type

Branch Code

Settle existing Instalment

Payment Method

Account No. to settle

Bank Name (Account to be settled)

Monthly Instalment (Account to be settled)

Settlement Amount

Payment Date

Do you consent to your information being shared in order to receive marketing regarding insurance and related products?

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?

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.

Compliance

Contact