���������������� �������������� �����������Would you like to be considered for annual, automatic credit limit increases?

YES NO APPLICANT SIGNATURE................................................................................

��������������������� �����������Permanent Temporary

New Credit Limit R................................... APPLICANT SIGNATURE................................................................................

�������������������� �������I agree that ������������������ & 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.

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Version 1 : March 2007 NCA reg no. : NCRCP 36

Date:.................... .............. ..............Time: .......................................................

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

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Mr Mrs Miss Ms Initials:......................................

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

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

SA/NAM/SWAZI ID no:

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

Account No:

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

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

Cellphone:

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

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

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

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

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

Are you a contract worker? Yes No Contract Expiry Date: .............

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

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

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

Limit Increase High Value Auto Increase

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

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

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Purchase Amount: R.......................

Purchase on plan: (Tick)

6 MTHS 12 MNTHS 24 MTHS

Deposit Offered by Customer: R ..............................

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

plan may be offered.

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Monthly salary before deductions: R ..............................

Other Monthly Income: R ..............................

Specify Other Income:......................................................................................

(eg. Secondary jobs, allowances, rental income)

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Rent: R ..............................

Levy: R ..............................

Rates: R ..............................

Child support: R ..............................

Medical aid: R ..............................

Life insurance policies: R ..............................

Funeral/retrenchment policy R ..............................

Investment policies/stokvel: R ..............................

Prepaid cellular/landline: R ..............................

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

Other monthly living expenses (including water & R ..............................

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

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