Existing Good Payers Customer Application - TAKE12 - Courts Fiji

CUSTOMER DETAILS

Customer ID or Account No *

Check the appropriate option*

Sole
Joint with Spouse
Joint with Other/Several
Business (Sole Trader/Partnership/Private)

New Customer Details

Requested Limit *

Term

Layout

Date of Birth *

Gender *

Age

Layout

Title *

First Name *

Middle Name *

Last Name *

Layout

Email Address *

Mobile No *

Layout (copy)

FNPF No *

Customer TIN *

Drivers License or Voter ID *

PERSONAL DETAILS

Layout (copy)

Father’s Name *

First

Last

Mother’s Name *

First

Last

Layout

Father's Original Village Name

Mother's Original Village Name

Marital Status

Layout (copy)

No of Children

No of Dependents

Ethnic Group *

Nationality *

Layout

Business Name

Business Reg No

Vehicle Details

Vehicle Type

Vehicle Registration No

Bank Details

Bankers Name

Bank Account No *

RESIDENTIAL STATUS

Layout

Home Address Line 1

Home Address Line 2

City/Town *

Contact Details

Landline *

Mobile *

Current Address Since

Property Type *

Previous Address Since

End Date

Reason

Delivery Address

Delivery Address Details

Layout

P.O.Box

Other

EMPLOYMENT DETAILS

Employer details

Employer

Employer Industry

Status

Layout

Occupation

No of Years/Months

Pay Frequency

Pay Amount

Annual Gross

Annual Net After Tax

Current Employment Start Date

Layout

Previous Employment Start Date

End Date

Reason

FINANCIAL STATUS

Layout

Monthly Net Income After Tax *

Additional Income *

Source of Additional Income *

Total *

Utility Bill Details

Utility Bills *

Utility Bill Breakdown *

Living Expenses Details

Living Expenses *

Living Expenses Breakdown *

Bank/Creditor Loans Details

Bank/Creditor Loans *

Bank/Creditor Loans Breakdown *

EMPLOYMENT DETAILS

Address Details

Address 1

Address 2

Address 3

Other Employee Details

Telephone No

Mobile No

City/Town *

Country *

Department Details

Department

Staff/Employment No

Date

Existing Good Payers Customer Application – TAKE12