Name

Known As

Surname

ID Number

Date of Birth

Physical Address

Work Address

Contact Number(Home)

Contact Number(Cell)

Email *

Employer

Department

Position

Employee number

Duration

Job Title

Contact Details

Gross salary

Net salary

Date of pay

Bank

Account number

Branch code

How many years or months your salary has been deposited in this account?

How did you hear about Bouticano Finance?

Name of person referred

Name of relative or family member?

Contact details of relative or family member

Are you listed on ITC

If Yes, do you know who listed you?

Do you have garnish?

Revolving loan

Fixed loan

Initiation fee

Did you understand?

Credit score *

Limit granted *

Any disputed amount in the last 3 months?

Personal Information

Employment

Salary

Banking Details

Other Credit Providers

installments

Other Credit Provides

Referrals

 If Yes, How much are you paying per month?

Has the Consultant Explained the following?

Office Use Only

Date

Review Date

Rent

School

Transport

Groceries

Accounts

Expenses

CLIENTS PERSONAL INFORMATION

Fixed Loan

Initiation Fee

Did you understand