APPLICATION FOR INSTALMENT FINANCE INDIVIDUAL

NEW
GOODS DESCRIPTION MODEL MAKE M&M CODE
USED

DEALER/BRANCH TEL NO.

CONTACT PERSON SALES PERSON FAX NO.

CASH PRICE (VAT INCL.) R VATABLE EXTRAS (VAT INCL.) INSTALMENT LEASE RENTAL

ADD COVER R RADIO /CD R TERM

LICENCE/REG FEE R NUMBER PLATES R RATE

CREDIT LIFE R WARRANTY R INITIATION FEE INCLUDE EXCLUDE

DEPOSIT/TRADE IN R OTHER R BALLOON / RESIDUAL R

FINANCE AMOUNT R OTHER R INSTALMENT R

PERSONAL DETAILS TITLE SURNAME ID NO.

FULL NAMES INITIALS DEPENDANTS

MALE FEMALE MARRIED OCOP COP SINGLE WIDOWED DATE MARRIED

HOME ADDRESS PERIOD

TEL(H) TEL(W) CELL FAX EMAIL

POSTAL ADDRESS CODE

PREVIOUS ADDRESS PERIOD

SPOUSE NAMES SPOUSE ID

NEXT OF KIN RELATIONSHIP

ADDRESS TEL

BOND DETAILS
BOND HOLDER AMOUNT OUTSTANDING

PROPERTY VALUE R INSTALMENT R /M PURCHASE PRICE R

DATE PURCHASED REGISTERED OWN NAME SPOUSE

RENTING
R

EMPLOYER DETAILS
EMPLOYER OCCUPATION

EMPLOYER ADDRESS TEL NO. OF YEARS

SALARY DATE PREVIOUS EMPLOYER NO. OF YEARS

SPOUSE EMPLOYER NO. OF YEARS

TEL OCCUPATION

BANK DETAILS BANK NAME BRANCH NAME BRANCH CODE

NAME OF ACCOUNT HOLDER ACCOUNT NO.

CREDIT CARD SAVINGS TRANSMISSION CURRENT

NEDBANK CLIENT
BRANCH ACCOUNT NO. INSTALMENTS PAID UP/CURRENT/TO BE SETTLED

TRADE REFERENCE
BRANCH ACCOUNT NO. INSTALMENTS PAID UP/CURRENT/TO BE SETTLED

ETHNIC GROUP
AFRICAN COLOURED INDIAN WHITE

LANGUAGE PREFERENCE
ENGLISH (PRIMARY) AFRIKAANS OTHER:
MFC/Individual App Form/2013/03

Signature Date

MFC, a division of Nedbank Limited Reg No 1951/000009/06, Vat Reg No 4320116074, 135 Rivonia Road, Sandton, 2196, South Africa. We subscribe to the Code of Banking Practice of The Banking Association South Africa and, for
unresolved disputes, support resolution through the Ombudsman for Banking Services. We are an authorised financial services provider. We are a registered credit provider in terms of the National Credit Act (NCR Reg No NCRCP16).

Page 1 of 2 APPLICATION FOR INSTALMENT FINANCE INDIVIDUAL

 APPLICATION FOR INSTALMENT FINANCE INDIVIDUAL
APPLICANT INITIALS SURNAME

ID NO.

PERSONAL APPLICATION FORM

SALARY DETAILS OWN SPOUSE

BASIC MONTHLY (EXCL CAR ALLOWANCE) R R

CAR ALLOWANCE R R

TOTAL SALARY (BASIC & CAR ALLOWANCE) R R

MONTHLY COMMISSION R R

NET TAKE HOME PAY R R

INCOME OTHER THAN SALARY/WAGES** R R

SOURCE OF OTHER INCOME**

TOTAL MONTHLY HOUSEHOLD INCOME (NET SALARY & OTHER) R

HOUSEHOLD EXPENSES PER MONTH

BOND PAYMENT / RENT R RATES, WATER AND ELECTRICITY R

VEHICLE INSTALMENTS (EXCLUDING THOSE TO BE SETTLED) R PERSONAL LOAN REPAYMENTS R

CREDIT CARD REPAYMENTS R FURNITURE ACCOUNTS R

CLOTHING ACCOUNTS R OVERDRAFT REPAYMENTS R

POLICY / INSURANCE REPAYMENTS R TELEPHONE PAYMENT R

TRANSPORT COSTS R FOOD AND ENTERTAINMENT R

EDUCATION COSTS R MAINTENANCE R

HOUSEHOLD EXPENSES R OTHER R

TOTAL MONTHLY HOUSEHOLD EXPENSES R

HOUSEHOLD SURPLUS/DISPOSABLE INCOME R

ARE YOU CURRENTLY LIABLE AS SURETY GUARANTOR CO-DEBTOR

SPECIFY DETAILS

IF YOU HAVE SIGNED SURETY OR CO-DEBTOR PLEASE INDICATE THE FULL AMOUNT OUTSTANDING

PLEASE TICK YOUR PREFERRED METHOD OF COMMUNICATION ALL EMAIL POST TELEPHONE SMS

DECLARATION BY CLIENT
1. I confirm that:

A.
I am not a minor.
B . I have never been declared mentally unfit by a court.
C. I am not subject to an administration order.
D. I do not have any current application pending for debt restructuring or alleviation.
E. I do not have any current debt re-arrangement in existence.
F. I have not previously applied for a debt re-arrangement.
G. I am not under sequestration.
H. I do not have applications pending for credit, nor open quotations as envisaged in section 92 of the National Credit Act.
If any of the above is incorrect, state which and give details:
2. I hereby give consent to the Credit Provider to make enquiries about my credit record with any credit agency and to obtain whatever information on me they might require to
process the credit application and/or application for insurance, and to share my payment behavior with any credit agency.
Y N
3. I hereby declare that all of the above information is true and correct.
MFC/Individual App Form/2013/03

Signature Date

MFC, a division of Nedbank Limited Reg No 1951/000009/06, Vat Reg No 4320116074, 135 Rivonia Road, Sandton, 2196, South Africa. We subscribe to the Code of Banking Practice of The Banking Association South Africa and, for
unresolved disputes, support resolution through the Ombudsman for Banking Services. We are an authorised financial services provider. We are a registered credit provider in terms of the National Credit Act (NCR Reg No NCRCP16).

Page 2 of 2 APPLICATION FOR INSTALMENT FINANCE INDIVIDUAL