Consumer Details
Title :
v
Surname:
First Name: Christian Name:
Initials
ID Number:
Language:
v
Marital Status:
v
Number Of Dependents :
+
-
Residential Address:
Postal Address:
Tel No (H).
Cell Num
Fax Num
Email  
Personal Work Details
Occupation/Title: Company Name:
Work Address
Work Num
Employment Bases:
v
Service Period Years Months
Supplementary Consumer Details
Title :
v
Surname:
First Name: Christian Name:
ID Number:
Cell Num
Email
Occupation/Title: Company Name:
Work Address
Work Num
Employment Bases:
v
Service Period Years Months
Supply Supplementary Consumer With Card:
References-First Relative/Friend(not residing with you)
Title
v
Initials:
Surname :
Residential Address
Tel No (H).
Cell Num
Relationship:
v
References-Second Relative/Friend(not residing with you)
Title
v
Initials:
Surname :
Residential Address
Tel No (H).
Cell Num
Relationship:
v
Affordability Assessment-Net Monthly Income
Main Consumer Income R
+
-
Supplementary Consumer Income R
+
-
Other Incomes:
Description: Income 1 R
+
-
Description: Income 2 R
+
-
Description: Income 3 R
+
-
Affordability Assessment-Monthly Expenses
Personal Loan
+
-
Bond/Rent Payments R
+
-
Vehicle Payments R
+
-
Credit Card Payments R
+
-
School Fees R
+
-
Short Term Insurance Premiums R
+
-
Medical Aid R
+
-
Pension Fund R
+
-
Policies R
+
-
Groceries R
+
-
Cell Phone Accounts R
+
-
Telephone Accounts R
+
-
TV Accounts R
+
-
Municipal Accounts R
+
-
Fuel R
+
-
Other R
+
-
Other Expense Description:
Other Credit Facilities
Credit ProviderAccount NumberMonthly InstallmentsFacility Granted
1.
+
-
+
-
2.
+
-
+
-
3.
+
-
+
-
4.
+
-
+
-
Other Card Holders
Name: Surname:
Name: Surname:
*Please note copies of the additional card holders ID’s will need to be faxed or emailed.
Fax No. (012) 348-2339
Email koopkrag@koopkrag.com
Assets
Registered Owner Of Property
v
Registered in the name of
Fixed Property Market Value R
+
-
Furniture R
+
-
Vehicles R
+
-
Investments R
+
-
Other Assets-Please Specify :
1 R
+
-
2 R
+
-
3 R
+
-
+
-
Liabilities
Bond Balance R
+
-
Loan Account Balances R
+
-
Bank Overdraft balance R
+
-
Asset Finance balance R
+
-
Surety R
+
-
Other Credit Facilities-Please Specify :
1 R
+
-
2 R
+
-
3 R
+
-
+
-
Debit Order
Bank Branch
Account Number Account Type
v
I hereby authorize the payment of my account by debit order on the
Credit Facility
+
-
+
-
Account Options
Select The Option by ticking the appropriate box:
1.Do you wish to receive your monthly statement via e-mail?
2.Would You Like to be considered for an automatic annual credit limit increase?
 
 
Acceptance Of Additional Fees
I hereby confirm that, although the following fees are optional, it can be added to my monthly account.
1.Card Protection Scheme
2.Group Insurance 2.View Group Insurance Document
3.Funeral Insurance 3.View Funeral Insurance Document
*Please note should you choose yes to option 2. or option 3. the relative documents must be downloaded and faxed or emailed to us.
Marketing
Where did you hear about us? Recruiting Member Number:

Are you or were you a member of another buying association?
Name: Account Number

You may select to be excluded from any of the following marketing options:
1.Email messages:
2.SMS messages
Consumer Declaration
Please indicate your answer by ticking the appropriate box
1. Are you or have you ever been declared mentally unfit by a High Court in South Africa ?
2. Are you insolvent or is there any indication that your estate could be placed under provisional sequestration ?
3. Are you currently under or have you ever applied for a debt review?
4. Do you have a re – arranged agreement in place with any credit provider as a result of debt counseling?
5. Do you have any dispute in process with a Credit Bureau ?
6 . Are you currently under an administration order in terms of section 74(1) of the Magistrate's Court Act ?
 
 
 
 
 
 
Supporting Documents
The total size of all the documents should not exceed 2MB:
ID:
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Latest Utility Bill:
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Latest Bank Statement:
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Latest Income Slip:
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**Alternatively please send these documents to us:
Fax No. (012) 348-2339
Email: koopkrag@koopkrag.com

Agreement
I have read the terms and conditions and agree to all the conditions.
 
Please make sure all the requried fields are completed