Credit Application Form

"*" indicates required fields

Full trading name*

Full registered name*

Registration no

VAT no

Type of entity, e.g. corporation, non-profit, individual, etc.*

Nature of business*

Operational since*

Postal address

Physical address

Address line 1*

Address line 2

Suburb / Township*

Town / City*

Municipality / District (if relevant)

Postal code*

Province*

Telephone*

Email*

Website

Name and designation of person responsible for payments*

Credit requested (Please state purpose)*

Amount*

Is this a monthly or an ad hoc credit requirement (Tick relevant box)*

Monthly

Ad Hoc

Bank*

Branch*

Account holder name*

Account number*

Type of account*

Contact number*

Please upload proof of account*

Max. file size: 64 MB.

Trade references

Reference 1

Company name

Company address

Contact name

Designation

Contact number

Account opened since

Credit limit

Reference 2

Company name

Company address

Contact name

Designation

Contact number

Account opened since

Credit limit

Reference 3

Company name

Company address

Contact name

Designation

Contact number

Account opened since

Credit limit

Application made by: (first, middle & last names)*

ID number*

Designation*

Cell number*

Email*

I hereby declare that I am duly authorized to make this application on behalf of

Name of Organisation

I also declare that the information contained herein is complete and accurate. This information is furnished on the understanding that it will be used to determine the amount and conditions of the credit to be extended. Furthermore, I hereby authorize the financial institutions listed in this credit application to release necessary information to the company from which credit is being applied for. I understand that, should this application be unsuccessful, a direct debit for the contracted amount/s must be entered into.

Date*

Please upload a copy of business registration document*

Max. file size: 64 MB.

Please upload a copy of signatory’s ID document*

Max. file size: 64 MB.