Sales Representative -Select Sales Representative (Not Required)- Chantel Wernich Eric Dladla Luan Coetzee

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):

Home Address :

Street 1:

Street 2:

Street 3:

Suburb :

City :

Postal Code:

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

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

I hereby give my consent to all related parties for the collection and use of this information. *