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Please confirm the following before we can proceed. If you are under debt review, we will not able to assist you, according to the national credit act. Please note that "DEBT REVIEW" is not the same as "BLACKLISTED"!

Debt Review | I hereby confirm the following:*

I am not under Debt Review
I earn more than R8500 p/m

I have a drivers license

YES
NO

Personal Detail. Rest assured that your personal info will be kept highly confidential

Full Names & Surname*

First Middle Surname

Phone*

Email*

ID Number*

Gender*

Male
Female

Are you married*

Yes
No
Divorced

If yes, how many year?

E.g 4 years

Address*

Street Address Address Line 2 City ZIP / Postal Code

Term at pressent address*

E.g 4 years

Type of residency*

Bonded
Bond free
Tenant

Next of Kin Name (Not living with you)*

First Last

Phone*

Address*

Street Address Address Line 2 City ZIP / Postal Code

Bank Name*

Account number*

Account Type*

Cheque
Savings

Employment Type*

Employed
Self-Employed

Vehicle Registration*

Personal Name
Business Name

Company Name*

Company Registration Number

Employer Name*

Job title*

How many years at current job?*

Work Phone*

Address*

Street Address Address Line 2 City ZIP / Postal Code

Gross income (Including ALL overtime, allowances and commissions)*

Nett income (Including ALL overtime, allowances and commissions)*

Other income for expample Rent etc.

Please specify

Bond or Rent*

Water and Electricity*

Vehicle installment/s*

Are you trading in this/these vehicle/s*

Yes
No

Personal loan installment/s*

Credit cards installment/s*

Furniture installment/s*

Clothing acc installment/s*

Policies & Insurance*

Telephone costs*

Transport costs*

Education costs*

ID

Paylslip (Latest 3 months)

Bank statement (Latest 3 months)

Divers License

Proof of residence

Consent*

Credit Provider Consent

I, the undersigned hereby authorize Blacklisted Vehicle Finance to obtain a Credit Bureau report in my name, via LUCID Legal Business Services (Pty) Ltd with registration number 2003/016694/07. I understand that Blacklisted Vehicle Finance will apply at multiple Financial Institutions, including but not limited to Normal Banking Groups in South Africa.

Consent*

Acknowledgement

I hereby confirm that the above info provided, is accurate and correct.