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Individual Loan Application Form
Branch Information
Branch
*
Account Officer
A/C No.
Balance
Personal Data
Surname
*
Forenames
*
Identification Number
*
Type of ID
Passport No.
Driver's Licence No.
Home Address
*
Number of years at this address
Telephone (work, cell, home)
*
Date of Birth
*
Age
Place of Birth
Occupation
*
Qualification
Sex
*
Select
Male
Female
Marital status
*
Select
Single
Married
Widowed
Separated
Name Of Spouse
Occupation Of Spouse
Income Of Spouse
Number Of Dependents
Home Ownership
Select
Owned
Rented
Mortgaged
Shared/Others
Business Activity
Type Of Business (e.g. retail, wholesale, service, manufacturing, farming)
Business Name
Business Address
City
Business Telephone
No. Of Years In The Business
Business Partner
No. Of Employees
Estimated Business Assets
Estimated Monthly Sales
Yes
No
Sole Proprietor/Partnership/Limited Company/Cooperative
Select
Sole Proprietor
Partnership
Limited Company
Cooperative
Registration/Licence No.
Who looks after your business when you're sick or away?
Yes
No
If yes, what type of business?
Yes
No
Status Of Employment
Select
Permanent
Contractual
Monthly income from Employment
Name Of Employer
Telephone Of Employer
Address Of Employer
Name Of Manager
Loan Information
How much do you want to borrow?
*
For how long? (Months)
*
Purpose of loan?
*
How much can you afford to pay? (Monthly)
*
Household and Business Assets - Item 1
Asset 1 - Year produced
Asset 1 - Model & Brand Name
Asset 1 - Acquisition Date
Asset 1 - Acquisition Cost
Asset 1 - Current Estimated Value
Household and Business Assets - Item 2
Asset 2 - Year produced
Asset 2 - Model & Brand Name
Asset 2 - Acquisition Date
Asset 2 - Acquisition Cost
Asset 2 - Current Estimated Value
Household and Business Assets - Item 3
Asset 3 - Year produced
Asset 3 - Model & Brand Name
Asset 3 - Acquisition Date
Asset 3 - Acquisition Cost
Asset 3 - Current Estimated Value
Household and Business Assets - Item 4
Asset 4 - Year produced
Asset 4 - Model & Brand Name
Asset 4 - Acquisition Date
Asset 4 - Acquisition Cost
Asset 4 - Current Estimated Value
Household and Business Assets - Item 5
Asset 5 - Year produced
Asset 5 - Model & Brand Name
Asset 5 - Acquisition Date
Asset 5 - Acquisition Cost
Asset 5 - Current Estimated Value
Yes
No
If yes, how much is your outstanding loan?
Name of Creditor
Yes
No
If yes, how much is his/her outstanding loan?
Name of Creditor (Spouse)
Name at least one creditor/supplier that you have borrowed from in the past (1)
Name at least one creditor/supplier that you have borrowed from in the past (2)
Yes
No
If yes, Amount?
Name of bank or institution?
Authorization
I confirm that the above information is true and correct to the best of my knowledge. I am aware that any false statement may be an immediate cause for denial of this loan.
*
In connection with this application, I authorise Empower Bank to obtain such other information as may be required. This authorisation includes obtaining information from suppliers, banks, bureau and all other creditors while releasing these institutions from liability under any law.
*
I have read and accept Empower Bank loan terms and conditions.
*
Signature of Applicant
*
Date
*
