PLEASE COMPLETE THIS APPLICATION FORM

TITLE *

INITIALS *

FULL NAME *

SURNAME *

ID NO *

GENDER *

STATUS *

HOME ADDRESS *

PERIOD LIVED HERE *

POSTAL ADDRESS *

PREVIOUS ADDRESS *

PERIOD LIVED HERE *

TEL (H) *

TEL (W) *

TEL (C) *

EMAIL *

SPOUSE NAME *

SPOUSE EMAIL *

NEXT OF KIN *

RELATIONSHIP *

ADDRESS *

TEL *

BOND DETAILS

BOND HOLDER *

AMOUNT OUTSTANDING *

PROPERTY VALUE *

INSTALLMENT PER MONTH *

PURCHASE PRICE *

DATE PURCHASED *

EMPLOYER DETAILS

EMPLOYER *

OCCUPATION *

EMPLOYER ADDRESS *

TEL *

NUMBER OF YEARS WORKED *

SALARY DATE *

PREVIOUS EMPLOYER *

NUMBER OF YEARS WORKED *

SPOUSE EMPLOYER *

NUMBER OF YEARS WORKED *

OCCUPATION *

TEL *

SALARY DETAILS

OWN BASIC MONTHLY SALARY *

OTHER *

SPOUSE BASIC MONTHLY SALARY *

OTHER *

BANK DETAILS

BANK NAME *

BRANCH NAME *

BRANCH CODE *

TYPE OF ACCOUNT *

NAME OF ACC HOLDER *

ACC NUMBER *

I hereby agree that the information above is true and correct *

I AGREE

DRIVING DETAILS

DO YOU HAVE A VALID DRIVER'S LICENSE? *

DRIVER'S LICENSE NUMBER *

DRIVING EXPERIENCE (ACTIVE) *

DO YOU TRAVEL ON DIRT ROADS? *

LANGUAGE PREFERENCE

CHOOSE YOUR LANGUAGE *

APPLICANT ID *

APPLICANT INITIALS *

APPLICANT SURNAME *

HOUSEHOLD INCOME DETAILS

GROSS REMUNERATION *

MONTHLY COMISSION *

CAR ALLOWANCE INCLUDED IN GROSS *

NETT TAKE HOME PAY *

INCOME OTHER THAN SALARY/WAGES *

SOURCE OF INCOME *

TOTAL MONTHLY HOUSEHOLD INCOME *

HOUSEHOLD & EXPENSES PER MONTH

BOND PAYMENT/RENT *

RATES, WATER & ELECTRICITY *

VEHICLE INSTALMENTS (EXC TO BE SETTLED) *

PERSONAL LOAN REPAYMENTS *

CREDIT CARD REPAYMENT *

FURNITURE ACCOUNT *

CLOTHING ACCOUNT *

OVERDRAFT ACCOUNT *

POLICY/INSURANCE REPAYMENT *

TELEPHONE PAYMENT *

TRANSPORT COST *

FOOD & ENTERTAINMENT *

EDUCATION COSTS *

MAINTENANCE *

HOUSEHOLD EXPENSES *

OTHER *

TOTAL MONTHLY HOUSEHOLD EXPENSES *

HOUSEHOLD SURPLUS/DISPOSABLE INCOME *

ARE YOU CURRENTLY LIABLE AS *

SPECIFY DETAILS

If you have signed or Co-Debtor, please include the full amount outstanding

I CONFIRM THAT: *

I am not a minor

I CONFIRM THAT: *

I am not under sequestration

If any of the above is incorrect, please provide details:

DECLARATION BY CLIENT

I hereby grant the Owner or Rental Agent of EZlend Wheels the right to communicate with me through any electronic / written media or verbally to make available to me, their product offering and to utilize my information for supporting products as communicated by one of the Credit Provider’s Partner. *

Yes

No

I hereby grant the Owner or Rental Agent of EZlend Wheels the right to increase my credit limit once every year to accommodate any value-added product needed and requested by me. *

Yes

No

I hereby declare that all information provided above is true and correct *

Yes

FULL NAME *

DATE *

PLEASE COMPLETE THIS APPLICATION FORM

BOND DETAILS

EMPLOYER DETAILS

SALARY DETAILS

BANK DETAILS

DRIVING DETAILS

LANGUAGE PREFERENCE

HOUSEHOLD INCOME DETAILS

HOUSEHOLD & EXPENSES PER MONTH

DECLARATION BY CLIENT

EZ Wheels South Africa is here.

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