Apply – EZ Wheels

PLEASE COMPLETE THIS APPLICATION FORM

TITLE *

INITIALS *

FULL NAME *

SURNAME *

ID NO *

GENDER *

CURRENT ADDRESS (and where car will be kept overnight) *

PERIOD LIVED HERE *

WORK ADDRESS (Head office and actual branch worked at) *

POSTAL ADDRESS *

PREVIOUS ADDRESS *

PERIOD LIVED HERE *

TEL (H) *

TEL (W) *

TEL (C) *

EMAIL *

SPOUSE NAME *

SPOUSE EMAIL *

NEXT OF KIN *

RELATIONSHIP *

ADDRESS *

TEL *

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

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 *

BOND DETAILS

BOND HOLDER / BANK *

AMOUNT OUTSTANDING *

PROPERTY VALUE

INSTALLMENT PER MONTH

PURCHASE PRICE

DATE PURCHASED

HOUSEHOLD / INCOME DETAILS PER MONTH

SELECT:

PRIVATE INDIVIDUAL

SELF-EMPLOYED

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 *

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

DECLARATION BY CLIENT

I hereby grant the Owner or Agent of EZ 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 Agent of EZ 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 *