INDIVIDUAL LOAN APPLICATION FORM

Loan Type

Payroll Loan

Business Loan

INDIVIDUAL APPLICANT DETAILS

Title

First Name

Surname

Maiden Name

Gender

Date Of Birth

Marital Status

Nationality

Cell Number

Highest Educational Qualification

Citizenship

Email Address

Residential Address

Permanent Address

Period at Current Address

Period at Previous Address

SPOUSE AND NEXT OF KIN DETAILS

SPOUSE DETAILS

Full Name

Phone Number

Email Address

Address

NEXT OF KIN 1

Full Name

Relationship

Email Address

Phone Number

Address

NEXT OF KIN 2

Full Name

Relationship

Email Address

Phone Number

Address

EMPLOYMENT DETAILS

BusinessEmployers Name

Job Title

Business Employers Address

Date of Employment

Name of Immediate Manager

Phone Number of Immediate Manager

Employment Status

Gross Salary

Net Salary

Employee Number

OTHER SOURCES OF INCOME

Re-order	SOURCE	GROSS	NET	INTERVALS	Weight	Operations
	SOURCE	GROSS	NET	INTERVALS	Item weight

more items

If Yes state the name and Relationship

PROPERTY OWNERSHIP

Rented

Employer Owned

Mortgage

Owned without Mortgage

Parents

List of Pledged Assets

BANK/MOBILE ACCOUNT DETAILS

Bank	Branch	Account Number

LOAN WITH OTHER INSTITUTION

INSTITUTION	MONTHLY INSTALLMENT	CURRENT LOAN BALANCE	MATURITY DATE

Loan Amount

Loan Purpose

Loan Tenure

6 Months

12 Months

18 Months

Other…

DECLARATION

I declare that the information given above is accurate and correct. I am aware that falsifying information automatically leads to decline of my loan application. I authorise Qupa Microfinance to obtain and use the information obtained for the purposes of this application from the recognised credit bureau. I authorise Qupa Microfinance to obtain references from friends, relatives, neighbors and business partners including visits to my home and verification of my assets. I undertake to provide all documents required by Qupa Microfinance and to update all records in the event of change of any personal details.

Full Name

Signature and Date

Sign above

Copy of ID, License, Passport

Current Payslip

Stamped 3 Months' Bank statement

Mobile statements

Proof of Residence/ Confirm Letter

FOR OFFICIAL USE ONLY

Received and checked by:

Name

Signature

Sign above

Date

Name

Signature

Sign above

Date

KYC CHECKLIST

Copy of ID, Licence, Valid Passport

Current Pay Slip

Stamped 3 Months' Bank Statement

Mobile Statements

Proof of Residence

Qupa Date Stamp