sefa Product Application Form

1 Accessible Development Financesefa Product Application Form01 LICENSED CREDIT PROVIDER (NCRCP 160) PAGEOF 11 loan Application FORMSECTION A: COMPANY INFORMATION(To be completed by borrowing legal entity)COMPANY DETAILSCIPC Registered NameTrading NameType of BusinessIndustry (Sector)Registration NumberRegistration DateDDMM CCYYT elephone NumberFax NumberE-mail AddressVAT Registration NumberTax Reference NumberPhysical AddressProvinceCodePostal AddressProvinceCodeShould sefa contact you for telemarketing purposes?Ye sNoPeriod in Business (Years)Number of Current EmployeesNew jobs expected to be createdHow did you hear about sefa?(Tick applicable box)RoadshowRadioWord of MouthOutdoor Advertising ( Billboard, Pamphlet, etc.)Print Media ( Magazine, Newspaper advert, etc)Other (please specify)Indicate how you would prefer to receive copies for your legal documents. (Tick applicable box)Collecting in person at sefa s offices?PostFax( ) - E-mailCONTACT PERSON/COMPANY REPRESENTATIVET itle (Prof/Dr/Mr/Ms)SurnameFirst Name(s)Contact Number(s)Cell( ) - Te l( ) - Fax( ) - E-mailMEMBERS/SHAREHOLDER DETAILSFull Name(s) and SurnamePercentage ShareholdingCOMPANY BRIEF BACKGROUND INFORMATION (Should you require more space please attach a separate page)02 LICENSED CREDIT PROVIDER (NCRCP 160) PAGEOF 11 FINANCIAL INFORMATION1 Total Finance RequiredOwners Contribution (Unencumbered)Source of FundsFinancial Year End of BusinessDDMM CCYYPERIODIC ABRIDGED FINANCIAL STATEMENT (Not applicable to Start-up businesses)(Less means a negative value that must be preceded by a minus sign.)

2 -1200 without any spaces or characters)Current Financial YearPrevious Financial YearPrevious Financial YearPrevious Financial YearPrevious Financial YearGross TurnoverRRRRRG ross ProfitRRRRR(Less) Gross Operating ExpensesRRRRRNet ProfitRRRRRASSETS AND LIABILITIEST otal Value of Fixed Assets RRRRRT otal Value of Current AssetsRRRRR(Less) Total Value of Current LiabilitiesRRRRR(Less) Total Value of Long Term LiabilitiesRRRRRN etworthRRRRRREFERENCESBANKING DETAILS OF THE COMPANYName of BankBranchType of AccountAccount NumberFacilitiesSecurity Held by Bank1 Please attach financial statements - if availableTRADE ACCOUNTST itle & Name of Contact PersonTitle & Name of Contact PersonName of BusinessName of BusinessContact NumbersCell ( ) - Contact NumbersCell ( ) - Te l( ) - Te l( ) - Fax ( ) - Fax ( ) - E-mail AddressE-mail AddressType of AccountCashCreditType of AccountCashCredit03 LICENSED CREDIT PROVIDER (NCRCP 160) PAGEOF 11 PROFESSIONALName & Surname of Accounting OfficerCompany NameContact Number(s)Cell( ) - Te l( ) - Fax( ) - E-mailDECLARATION AND CONSENTI/We, the undersigned declare that the information provided in this Application form is to the best of my/our knowledge true and complete.

3 I/We also understand that any wilful misrepresentation of the information in this Application form will disqualify my/our Application and may lead to legal action against me/us including the laying of criminal charges against me/us as sureties as well as against the entity I/we represent for furnishing false statement or information to the Small Enterprise Finance Agency (SOC) Ltd (sefa).I/We hereby grant sefa consent to perform an entity/personal search and check on my/our records with any other party ( credit bureau and/or a government agency) relating to this further authorise sefa to disclose my/our personal information to these parties to obtain the information they require and acknowledge that sefa will never disclose more information than they are required warrants that it will treat your personal information as confidential and take all necessary steps to protect your information as required by the Protection of Personal Information Act of 2013.

4 We will only disclose your information if: The law requires us to do so; It is in the public interest to do so; Our interests require disclosure; or You have given us your Name(s)Full Name(s)DesignationDesignationSignatureSi gnaturePlacePlaceDateDDMM CCYYDateDDMM CCYY04 LICENSED CREDIT PROVIDER (NCRCP 160) PAGEOF 11 MEMBER/SHAREHOLDER/PARTNER DETAILSS urnameFirst Name(s)ID NumberGender (tick applicable box)MaleFemaleNationality (Citizenship)RaceAfricanIndianWhiteOther Please specify:Do you have any disability?YESNOIf YES, please give details:Involvement in BusinessActive PartnerSilent PartnerIf Active - Operational Responsibility:Physical AddressProvinceCodePostal AddressProvinceCodeNumber of Years at Residential AddressPrevious Residential Address (if less than 5 years at current address)ProvinceCodeContact detailsTel (H) ( ) - Tel (B) ( ) - Fax( ) - Cell( ) - E-mailMarital Status (Tick applicable Box)SingleMarried in community of propertyMarried out of community of propertywith or without accrualOtherIf other, provide details:Number of DependantsAge Next of Kin (not staying with you)SurnameFirst Name(s)RelationshipContact DetailsCell( ) - Te l( ) - E-mailResidential AddressProvinceCodePREVIOUS EXPERIENCE AND CAREER HISTORYE mployerPositionPeriodLOAN Application FORMSECTION B.

5 PERSONAL INFORMATION(To be completed by each shareholder/trustee of the borrowing legal entity Pty Ltd, Ltd, Trust, etc.)05 LICENSED CREDIT PROVIDER (NCRCP 160) PAGEOF 11 REFERENCESPERSONAL TRADE ACCOUNTSName of Contact PersonName of Contact PersonName of BusinessName of BusinessContact NumbersCell ( ) - Contact NumbersCell ( ) - Te l( ) - Te l( ) - Fax ( ) - Fax ( ) - E-mail AddressE-mail AddressType of AccountCashCreditType of AccountCashCreditPERSONAL BANKING DETAILS OF APPLICANT / COMPANY REPRESENTATIVEName of BankName of BankBranchBranchType of AccountType of AccountAccount NumberAccount NumberFacilitiesFacilitiesSecurity Held by BankSecurity Held by BankINCOMEE mployedSelf Employed (tick applicable box)Name of Employer/ Name of BusinessPhysical AddressProvinceCodePosition Held/ Nature of BusinessSalary/ DrawingsRPeriod of Employment/ Period in Business06 LICENSED CREDIT PROVIDER (NCRCP 160) PAGEOF 11 MONTHLY INCOME AND EXPENDITURE STATEMENTNet Salary (Income)ROther Income (please specify)ROther Income (please specify)RTOTAL INCOMER(LESS) EXPENSES (all values must be preceded by a minus sign.)

6 -1200 without spaces or characters such as full stops (.) or commas (,))Bank ChargesRMortgage Bond(s)RDonationsREntertainmentRClothing Account(s)RCellular Phone Contract(s)RDomestic WorkerREducation FeesRGroceriesRSchool TransportRWater and LightsRRates and TaxesRSubscriptions (TV, Papers, etc.)RInvestmentsRLife PoliciesRPetrolRShort Term InsuranceRLandline RentalRAlarm and Tracking ContractsROther (please specify)ROther (please specify)R(LESS) TOTAL EXPENSESRSURPLUS (DEFICIT)RSTATEMENT OF ASSET AND LIABILITIESA ssetsRLiabilitiesRResidential Property(ies)Mortgage Bond(s):Motor Vehicle(s)Vehicle Finance:Household EffectsPersonal Loans:Equity in BusinessesOther Assets (please specify)Other Liabilities (please specify):Net EquityTotal AssetsRTotal LiabilitiesR07 LICENSED CREDIT PROVIDER (NCRCP 160) PAGEOF 11 PERSONAL RECORDYESNO(Tick applicable box)1. Are you currently undergoing debt counselling or do you have a pending debt counselling Application ?

7 2. Are you undergoing debt restructuring?3. Have you ever been sequestrated?4. If so, have you been rehabilitated?5. Have you ever been found guilty of a criminal offence?6. Have you ever reached a compromise with creditors or had repayment problems?7. Have you ever been summoned or had judgements taken against you?8. Have you signed surety for anyone else?Kindly give details in respect of any YES answers above:DECLARATION AND CONSENTI, the undersigned declare that the information provided in this Application form is to the best of my knowledge true and complete. I also understand that any wilful misrepresentation of the information in this Application form will disqualify my Application and may lead to legal action against me and/or the entity I represent including the laying of criminal charges against me as sureties as well as against the entity I represent for furnishing false statement or information to the Small Enterprise Finance Agency (SOC) Ltd (sefa).

8 I hereby grant sefa consent to perform an entity/personal search and check on my records with any other party ( credit bureau and/or a government agency) relating to this further authorise sefa to disclose some of my personal information to these parties to obtain the information they require and acknowledge that the sefa will never disclose more information than they are required warrants that it will treat your personal information as confidential and take all necessary steps to protect your information as required by the Protection of Personal Information Act of 2013 (POPI). We will only disclose your information if: The law requires us to do so; It is in the public interest to do so; Our interests require disclosure; or You have given us your Name(s)DesignationSignaturePlaceDateDDMM CCYYSPOUSE S DECLARATION AND CONSENT (If married in community of property)I have obtained my spouse s consent to enter into this Credit Facility and for credit check with any credit reference agency.

9 I understand that I will be liable for fraud should I falsely declare my spousal Name(s)DesignationSignaturePlaceDateDDMM CCYY08 LICENSED CREDIT PROVIDER (NCRCP 160) PAGEOF 11 MEMBER/SHAREHOLDER/PARTNER DETAILSS urnameFirst Name(s)ID NumberGender (tick applicable box)MaleFemaleNationality (Citizenship)RaceAfricanIndianWhiteOther Please specify:Do you have any disability?YESNOIf YES, please give details:Involvement in BusinessActive PartnerSilent PartnerIf Active - Operational Responsibility:Physical AddressProvinceCodePostal AddressProvinceCodeContact detailsTel (H) ( ) - Tel (B) ( ) - Fax( ) - Cell( ) - E-mailMarital Status (Tick applicable Box)SingleMarried in community of propertyMarried out of community of propertywith or without accrual?OtherIf other, provide details:Number of DependantsAge Next of Kin (not staying with you)SurnameFirst Name(s)RelationshipContact DetailsCell( ) - Te l( ) - E-mailResidential AddressProvinceCodeREFERENCESTRADEName & Surname of Contact PersonName of BusinessContact NumbersCell( ) - Te l( ) - Fax( ) -E-mail AddressAccount NumberType of AccountCashCreditLOAN Application FORMSECTION C: SURETY form (To be completed by the sureties of the borrowing entity)09 LICENSED CREDIT PROVIDER (NCRCP 160) PAGEOF 11 BANKINGName of BankBranchType of AccountAccount NumberFacilitiesSecurity Held by BankPROFESSIONALName & Surname of Accounting OfficerCompany NameContact Number(s)Cell( ) - Te l( ) - Fax( ) - E-mailPERSONAL RECORDYESNO(Tick applicable box)1.

10 Are you currently undergoing debt counselling or do you have a pending debt counselling Application ?2. Are you undergoing debt restructuring?3. Have you ever been sequestrated?4. If so, have you been rehabilitated?5. Have you ever been found guilty of a criminal offence?6. Have you ever reached a compromise with creditors or had repayment problems?7. Have you ever been summoned or had judgements taken against you?8. Have you signed surety for anyone else?Kindly give details in respect of any YES answers above:DECLARATION AND CONSENTI, the undersigned declare that the information provided in this Application form is to the best of my knowledge true and complete. I also understand that any wilful misrepresentation of the information in this Application form will disqualify my Application and may lead to legal action against me and/or the entity I represent including the laying of criminal charges against me as sureties as well as against the entity I represent for furnishing false statement or information to the Small Enterprise Finance Agency (SOC) Ltd (sefa).