| By completing and submitting this application,
the applicant confirms that: |
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I am not a minor. |
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I have never been declared mentally unfit by a
court. |
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I am not subject to an Administration
Order. |
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I do not have any current application pending
for debt restructuring or alleviation. |
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I do not have any current debt re-arrangement
in existence. |
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I have not previously applied for a debt
re-arrangement. |
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I am not under sequestration. |
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I do not have applications pending for credit,
nor open quotations as envisaged in
section 92 of the National Credit
Act. |
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I hereby declare that the information provided
by me is true and correct. |
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| We will not disclose any personal information
to any party. |
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| I would like to be included in any
Telemarketing Campaign. |
Y |
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N |
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| I would like to be included in any Marketing
List that you may sell or distribute. |
Y |
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N |
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| I would like to be included in any mass
distribution of emails or SMS messages. |
Y |
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N |
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| - I understand that I will be liable for a
monthly service fee. |
| - I hereby consent to this Credit Provider
making enquiries regarding my credit history bureau. |
- I consent to this Credit Provider
reporting the conclusion of any credit agreement with me to the National
Loans
Register in compliance with this Credit Provider's
obligation under the National Credit Act. |
| - I hereby declare that the information
provided by me is true and correct. |
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| Signature of Applicant
_________________________________________________ Date
__________________________ |