PERSONAL DETAILS

Title

Surname

Full Names

Initials

ID Number

Date of birth

Client Subtype Client Subtype SA Citizen Residing in SA Asylum Seeker Refugee Foreign National Residing in SA SA Citizen Residing Abroad

Sex Sex Male Female

Ethnic Group Ethnic Group African Coloured Indian White

Language preference Language preference English Afrikaans Other

Marital status Marital status Single Married Divorced Widowed

If married, how married? If married, how married? COP OCOP Customary / Tribal law Married under foreign law

Date married

ADDRESS AND CONTACT INFORMATION

Home address

Postcode

Residential status

Period at address

Country of residence

Postal address

Postcode

Residential address/Geographic location

Tel (h)

Tel (w)

Cell

Email

Do you have tax obligations, tax liabilities or tax residencies outside SA? Do you have tax obligations, tax liabilities or tax residencies outside SA? Yes No

Are you a US citizen, a US person or a US national? Are you a US citizen, a US person or a US national? Yes No

Are you a registered VAT vendor? Are you a registered VAT vendor? Yes No

If ‘Yes’, VAT reg no

SPOUSE INFORMATION

Spouse identity no

Spouse name

Relationship

NEXT OF KIN INFORMATION

Next of kin

Address

Tel

EMPLOYER DETAILS

Current employer

Address of employer

No of years with employer

Occupation

Industry

Salary date

BANKING DETAILS

Bank name

Account no

Type of account: Type of account: Savings Current

Source of income Source of income Salary earner Self-employed Commission Director Pension Maintenance Court order Member of a corporation

MONTHLY INCOME AND EXPENSES

Applicant income details

Car allowance

Basic salary

Overtime

Commission

Source of other income (eg maintenance)

Other

Net salary

Total salary

Total monthly income

Spouse/Partner income details

Basic salary

Car allowance

Overtime

Commission

Other household income

Other

Net salary

Total salary

Total monthly income

Household expense details

Bond payment

Vehicle instalments (excl.those to be settled)

Clothing accounts

Credit card payments

Transport costs

Policy/Insurance premiums

Rates, water and electricity

Education costs

Furniture accounts

Personal-loan repayments

Overdraft payments

Property rent

Food and entertainment

Telephone payments

Other

Maintenance

Total monthly income

Total monthly household expenses

Less: Total monthly household expenses

Total monthly disposable income

I give consent to 121 Motors to share my personal detail with various financial institutions for the purpose of this application. I give consent to 121 Motors to share my personal detail with various financial institutions for the purpose of this application. AGREE

Date

Applicant's signature