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Full Name:

Marital Status

Gender

ID Number

Nationality

Date of Birth

Residential Address

Years

Months

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Please give details for your next of kin with your spouse and two other details

Permanent Address

Full Name:

Address

Contact Number

Relationship

Business/Employee's Name

Business/Employee's Address

Name of immediate manager

Your job title

Date of employment

Manager's Phone Number

Employement Status

Employement Number

Salary Currency

Gross Salary

Net Salary

Are you related to any Qupa MFI employees or directors

List of pledged assests

Asset Name

Serial Number

Banking / Mobile Account Details

Bank

Branch

Account Number

Loan amount in ZWL

Loan purpose

Loan duration (months)

How many months of life cover cover would you like?

Customer Signature

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