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Personal Details

Title

Full Names

ID number

Gender

Male

Female

Telephone

Fax

Cell phone

E-mail

Dependents

Marital status

Date married

Marital contract

Spouse Details :

Spouse ID number

Spouse Full names

Telephone (h)

Telephone (W)

Fax

Cell phone

E-mail

Address Details

Current address

Residential Status

Residential address 1

Residential address 2

Residential City/Town

Province

Code

Period at address (YYMM)

Bond with which bank

Bond account number

Previous address

Residential Status

Residential address 1

Residential address 2

Residential City/Town

Province

Period at address (YYMM)

Next of kin

(Note:Next of kin not residing at the same address as yourself)

Full Names

Relationship

Relative address 1

Relative address 2

Relative Suburb

Province

Postal Code

Telephone

Cell phone

Employer details

Employer

Occupation

Employer Address 1 Employer Address 2 Employer Suburb Employer Postal Code

Telephone

Period of Employment (YYMM)

Previous employer name and address

Period of previous employment (YYMM)

Salary date

Spouse employer

Spouse occupation

Number of years (spouse)

Telephone (spouse employer)

Bank details

Bank name

Branch name

Branch code

Name of account holder

Account number

Type of account

Ethnic group

African

Coloured

Indian

White

Salary Details	Own	Spouse
Basic monthly (exlc. car allowance)
Car allowance
Total salary (basic and car allowance)
Monthly commission
Net take home pay
Income other than salaries/wages (other income as per bank statement)
Sources of other income
Total monthly household income (net salary & other)

Household expenses per month

Bond payment/rent		Rates, Water & Electricity
Vehicle instalments (excluding those to be settled)		Personal loan repayments
Credit card repayments		Furniture accounts
Clothing accounts		Overdraft repayments
Policy/insurance payments		Telephone payments
Transport costs		Food and entertainment
Education costs		Maintenance
Household expenses		Other
Total monthly household expenses
Household surplus/disposable income
Are you currently liable as Surety, Guarantor or Co-debtor
Specify details
If you have signed surety or co-debtor please indicate the full amount outstanding

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 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 give details:
I. I hereby grant the Credit provider the right to communicate with me through any electronic/written media or verbally in order to make available to me, their product offering. Y or N

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 have to process the application. I also give consent to the Credit Provider to share my payment behaviour with any credit agency.
I hereby grant the Credit Provider the right to increase my Credit Limit once every year to accommodate any Value Added Products needed and requested by me.

Full Names and Surname: Date:

Kindly email or fax the required documents if you are unable to upload them. Please quote all documents with your reference number, which you'll get on the next page.
Fax: 086 531 8132
E-mail: info@autorefin.co.za

Payslip:

Id:

Drivers License:

Proof of Address:

Other:

Finance Details

Asset Details

Personal Details

Spouse Details :

Address Details

Current address

Previous address

Next of kin

Employer details

Bank details

Ethnic group

Salary Details

Own

Spouse

Household expenses per month