Koopkrag Credit/Loan Application MEMBER PERSONAL DETAILSRequire fields marked with *Member NumberMember TitleSpouse TitleMember Name + Surname *Spouse Full NamesMember Identification Number *Please enter a valid 13-digits South African ID number0 / 13Spouse Identification NumberPlease enter a valid 13-digits South African ID number0 / 13Mobile *Spouse MobileEmailSpouse EmailStreet Address *PO BoxSuburb *SuburbCity *CityProvince *ProvincePostal Code *Postal CodeMember Employment Bases *Please selectPermanentSelf-EmploymentContractedCommission EarnerPensionerSpouse Employment BasesPlease selectPermanentSelf-EmploymentContractedCommission EarnerPensionerMember Occupation *If pensioner, please write ‘Pensioner’Spouse OccupationIf pensioner, please write ‘Pensioner’Employer *If pensioner, please write ‘Pensioner’Spouse EmployerIf pensioner, please write ‘Pensioner’Maritial StatusMarried – By ante nuptial contractMarried – In community of propertyWidow/WidowerUnmarriedDivorcedCustomary LawAFFORDABILITY ASSESSMENTRequire fields marked with *Monthly IncomeGross Salary – Applicant *ZARGross Salary – SpouseZAROther Income – ApplicantZAROther Income – SpouseZARPlease specifyPlease specifyTotal Income – ApplicantTotal Income – SpousePayslip DeductionsMedical Aid – ApplicantZARMedical Aid – SpouseZARPension / Provident Fund – ApplicantZARPension / Provident Fund – SpouseZARPAYE – ApplicantZARPAYE – SpouseZARUIF – ApplicantZARUIF – SpouseZAROther Deductions – ApplicantZAROther Deductions – SpouseZARTotal Deductions – ApplicantTotal Deductions – SpouseNet Salary – ApplicationNet Salary – SpouseMonthly ExpensesAccommodation Expense – ApplicantZARAccommodation Expense – SpouseZARTransport Expense – ApplicantZARTransport Expense – SpouseZARFood Expense – ApplicantZARFood Expense – SpouseZAREducation Expense – ApplicantZAREducation Expense – SpouseZARMedical Expense – ApplicantZARMedical Expense – SpouseZARMaintenance Expense – ApplicantZARMaintenance Expense – SpouseZARWater & Electricity – ApplicantZARWater & Electricity – SpouseZAROther Expenses – ApplicantZAROther Expense – SpouseZARTotal Expenses – ApplicantTotal Expenses – SpouseAccountsAsset Finance – ApplicantZARAsset Finance – SpouseZARPersonal Loans – ApplicantZARPersonal Loans – SpouseZARCredit Cards – ApplicantZARCredit Cards – SpouseZARBond Repayments – ApplicantZARBond Repayments – SpouseZARCellphone Expense – ApplicantZARCellphone Expense – SpouseZARMicro Loans – ApplicantZARMicro Loans – SpouseZARSecurity – ApplicantZARSecurity – SpouseZARInsurance – ApplicantZARInsurance – SpouseZARClothing – ApplicantZARClothing – SpouseZARGeneral Retail – ApplicantZARGeneral Retail – SpouseZARTotal Accounts – ApplicantTotal Accounts – SpouseMin Bond Repayment – ApplicantZARMin Bond Repayment – SpouseZARDisposable IncomeDisposable Income Total – ApplicantDisposable Income Total – SpouseASSETS & LIABILITIESIf applicableAssetsLiabilitiesRegistered Owner of PropertyYesNoBond BalanceZARRegistered in the name ofLoan Account BalanceZARFixed Property Market ValueZARBank Overdraft BalanceZARFurnitureZARAsset Finance BalanceZARVehiclesZARSuretyZAROther AssetsZARE.g. InvestmentsOther LiabilitiesZARTotal AssetsTotal LiabilitiesREFERENCESTwo Relatives – Not residing with youWhere did you hear about Koopkrag for the first time? *First Reference Title *Second Reference Title *First Reference Initials *Second Reference Initials *First Reference Surname *Second Reference Surname *First Reference Residential Address *Second Reference Residential AddressMobile *Mobile *Alternative NumberAlternative NumberRelationshipRelationshipCONSENT AND SUBMISSIONPlease complete where applicableBank Details for Transfer of the LoanBank Name *Branch NumberAccount Holder Name *Account Number *Account Type *Credit Facility ApplicationAsset FinanceRepayment Period (months)Period in monthsAmount (applying for)Description of ItemShort Term / Personal LoanRepayment Period (months)Period in monthsAmount (applying for)Reason for Personal LoanCredit Application DeclarationAre you or have you ever been declared mentally unfit by a High Court in South Africa? * *YesNoAre you insolvent or is there any indication that your estate could be placed under provisional sequestration? *YesNoAre you currently under or have you ever applied for a debt review? *YesNoDo you have a re-arranged agreement in place with any credit provider as a result of debt counseling? *YesNoDo you have any dispute in process with a Credit Bureau? *YesNoAre you currently under an administration order in terms of section 74(1) of the Magistrate's Court Act? *YesNoTerms and Conditions *Yes, I agree with the privacy policy and terms and conditions. Cost of Credit *I agree with the membership fees as per the Cost of CreditPlease upload ID Document *Drag and Drop (or) Choose FilesPlease upload Proof of Residence *Drag and Drop (or) Choose FilesPlease upload Proof of Income (Latest Payslip and Bank statements) *Drag and Drop (or) Choose FilesPlease attach your Latest Payslip and 3 months bank statementsSigned at *Date *Date application completedApplicant's Signature *Start signing your signature hereYour browser does not support e-Signature field.Spouse SignatureStart signing your signature hereYour browser does not support e-Signature field.If applicableSubmitSave as Draft
