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CRB AFRICA - Individual Credit Report Request Form

This document is an individual credit report request form. It requests the applicant's personal details such as name, date of birth, ID numbers, addresses, employment information, and reason for requesting a credit report. The applicant must provide valid ID and sign to authorize the credit bureau to send the report to the specified address. Instructions note that names must match ID and ID/passport are mandatory based on nationality. The credit bureau official section is for verifying details and generating the report.

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Ben Musimane
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788 views2 pages

CRB AFRICA - Individual Credit Report Request Form

This document is an individual credit report request form. It requests the applicant's personal details such as name, date of birth, ID numbers, addresses, employment information, and reason for requesting a credit report. The applicant must provide valid ID and sign to authorize the credit bureau to send the report to the specified address. Instructions note that names must match ID and ID/passport are mandatory based on nationality. The credit bureau official section is for verifying details and generating the report.

Uploaded by

Ben Musimane
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Individual Credit Report Request Form

A. This section to be completed by the person requesting for the report (NB: full name as
appears on primary ID document)
Surname: Other Names: Date Of Birth: Gender:
Male/Female

National ID/Alien Passport No: Pin Number: Nationality:


Certificate

Postal Address: Telephone Contacts:


Postal Address: …………………………… Home: ………………………………………………………
Postal Code: ………………………………. Mobile: ……………………………………………………..
Town: ……………………………………… Work: ……………………………………………………….
Country: …………………………………. Email Address: ……………………………………………..

Home Physical Address:


House Number: ………………………………………………………………………………………………………
Estate or Street: ………………………………………………………………………………………………………
Town: ………………………………………………………………………………………………………………….
Employment/Business Information (Please tick as applicable);

Employment Status: [E] Employed. [S] Self-Employed.

Employer Name (in full – no abbreviations or acronyms)

Employer Address:

Postal Address: …………………………… Postal Code: ……………………………….


Town: ………………………………………. Country: …………………………………….

Employer Station: Employer Country: Employment Designation: Employment Duration:

Previous Employer Name (if less than one year at current)

Previous Employer Address (in full stating postal address, town, code and street addresses)
Postal Address ……………………………….. Town: ……………………………………….
Postal Code: ………………………………………….. Country: ……………………………………..
Last Employer Station: Employer Country: Last Employment Employment Duration:
Designation:
Kindly state your Reasons for requesting for the Credit Report:

For my own interest.

I was Denied Credit: Name of Institution……………………………………………………………..

Annual Report:

I would like to receive my credit reports and any other correspondence via:

Email Postal address

I certify that the information/answers and documentation provided in response to the questions
herein are true, complete and authentic.
I understand that the presentation of forged documents or the passing off of any documents issued by a
lawful authority to another person as my own, for purposes of obtaining any right or privilege, is a
criminal offence.

I confirm that I want my credit report delivered to me through the e-mail/postal address
indicated herein and hereby authorize CRBAfrica to mail/deliver/send my credit report to the
e-mail/postal address indicated herein. I release CRBAfrica and its officers, employees and
agents from all claims, actions or proceedings of whatsoever nature and howsoever arising,
suffered or incurred in connection with CRBAfrica sending/delivering/mailing my credit
report to the addresses that I have provided herein.

Name…………………………………………….Date…………………………Sign………………………….

How to complete the Individual Credit Request Form:


1. Names must appear as they do on ID if Kenyan/Alien Certificate or Passport if alien.
2. ID and PIN certificate are mandatory for Kenyan Nationals; Alien Certificate and
Passport is mandatory for aliens.

OFFICIAL USE:
Verified: ……………………………………………………………………………………………………..
Report generated: ………………………………………………………………………………………….
CRBAfrica Staff Name: ………………………………………Signature: ……………………………….
Date: ……………………………….

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