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CREDIT EVALUATION APPLICATION (Existing Acc) Date:.................... .............. ..............Time: .......................................................

Limit Increase

Branch Name:....................................................................................................

Contact person at Branch: ...............................................................................

High Value

Auto Increase

Contact telephone no at Branch: .....................................................................

PERSONAL DETAILS

PURCHASE DETAILS Purchase Amount: R.......................

Mr

Mrs

Miss

Ms

Initials:......................................

Purchase on plan: (Tick)

Surname:................................. .................................... .....................................

6 MTHS

12 MNTHS

24 MTHS

First Names: ............................Name by which known: .....................................

Deposit Offered by Customer:

SA/NAM/SWAZI ID no:

Please note that should you not qualify for the above mentioned plan,an alternate

R ..............................

Date of birth: (dd/mm/yy):........ .................................... ....................................

plan may be offered.

Account No:

MONTHLY INCOME

Home telephone: ..................... ....................................Dialing Code: ................

Monthly salary before deductions:

R ..............................

Alternate telephone: ................ ....................................Dialing Code: ................

Other Monthly Income:

R ..............................

Cellphone:

Specify Other Income:...................................................................................... (eg. Secondary jobs, allowances, rental income)

OCCUPATION DETAILS:

MONTHLY EXPENSES

Occupation/Job: ...................... .................................... .....................................

Rent:

R ..............................

Company or employer's name: .................................... .....................................

Levy:

R ..............................

Work telephone: ......................Dialing Code: ..............Ext:...............................

Rates:

R ..............................

Employee No:.......................... .................................... ....................................

Child support:

R ..............................

Name of manager/supervisor: . .................................... ....................................

Medical aid:

R ..............................

Are you a contract worker? Yes

Life insurance policies:

R ..............................

Funeral/retrenchment policy

R ..............................

No

Contract Expiry Date: .............

BANK DETAILS

Investment policies/stokvel:

R ..............................

Bank Name:........................................................................................................

Prepaid cellular/landline:

R ..............................

Branch Name / Code:.........................................................................................

Transport expenses: (Petrol, diesel, taxi, bus, train)

R ..............................

Cheque Account Number Only:..........................................................................

Other monthly living expenses (including water &

R ..............................

electicity, food, clothing, school fees, medical expenses)

REQUEST FOR AN AUTOMATIC CREDIT LIMIT INCREASE Would you like to be considered for annual, automatic credit limit increases? YES

NO

APPLICANT SIGNATURE................................................................................

Permanent

Temporary

New Credit Limit

R ...................................

REQUEST FOR A CREDIT LIMIT DECREASE APPLICANT SIGNATURE................................................................................

NATIONAL CREDIT ACT COMPLIANCY I agree that FOSCHINI RETAIL GROUP & any of its associate companies may: - verify all information supplied on the Credit Evaluation Form; - make enquiries and receive information from any person, credit bureau or financial institution in order to establish my credit worthiness; - provide information on the conduct of my account to any credit bureau or credit provider.

APPLICANT SIGNATURE.................................................................................................

FOR OFFICE USE ONLY BANK CODE OUTCOME: (Tick) A CREDIT LIMIT DEPOSIT

CREDIT PLAN

B

C

D

E

F

REASONS FOR DECLINE: AUTHORISED SIGNATURE:

Version 1 : March 2007

NCA reg no. : NCRCP 36


27376 - Credit Eval