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Application
POLICY/INSURANCE REPAYMENT
*
TELEPHONE PAYMENT
*
TRANSPORT COST
*
FOOD & ENTERTAINMENT
*
EDUCATION COSTS
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MAINTENANCE
*
HOUSEHOLD EXPENSES
*
OTHER
*
TOTAL MONTHLY HOUSEHOLD EXPENSES
*
HOUSEHOLD SURPLUS/DISPOSABLE INCOME
*
ARE YOU CURRENTLY LIABLE AS
*
SURETY
GUARANTOR
CO-DEBTOR
NONE OF THE ABOVE
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 declare that all information provided above is true and correct
*
Yes
FULL NAME
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DATE
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