ZB Chambers, 2nd Floor, Corner 1st Street & George Silundika
Harare, Zimbabwe
Tel: +263 867 700 2005 Email: [email protected]
INDIVIDUAL LOAN APPLICATION FORM
Payroll Loan: Bus Loan: Loan Type:
INDIVIDUAL LOAN APPLICATION FORM
Title (Mr./Mrs./Dr/Prof): First Name: Surname:
Maiden Name: Gender: Date Of Birth:
Marital Status: Nationality: ID Number:
Cell Number: WhatsApp: Highest Educational Qualification:
Citizenship: Email Address:
Residential Address: Permanent Address:
Period at Current Address: Years: Months:
Period at Previous Address: Years: Months:
SPOUSE AND NEXT OF KIN DETAILS
SPOUSE DETAILS NEXT OF KIN 1
Full Name: Full Name:
Phone Number: Relationship:
Email Address: Phone Number:
Address: Email Address:
Address:
NEXT OF KIN 2
Full Name:
Relationship:
Phone Number:
Email Address:
Address:
EMPLOYMENT DETAILS
Business/Employer’s Name: Job Title:
Business/Employer’s Address: Date of Employment:
Name of Immediate Manager: Phone Number of Immediate Manager:
Status of Employment: Permanent: Contract: Part time: Self Employed:
Gross Salary: Net Salary: Employee Number:
OTHER SOURCES OF INCOME
SOURCE GROSS NET INTERVALS
Are you related to any Qupa MFI employeees or directors? Yes: No:
If YES state the name and relationship:
PROPERTY OWNERSHIP
Rented: Employer Owned: Mortgaged: Owned Without Mortgage: Parents owned:
LIST OF PLEDGED ASSETS
1: 1:
2: 2:
BANK/MOBILE ACCOUNT DETAILS
BANK BRANCH ACCOUNT NUMBER
LOAN WITH OTHER INSTITUTION (ALSO INCLUDE QUPA LOAN)
INSTITUTION MONTHLY CURRENT LOAN MATURITY DATE
INSTALLMENT BALANCE
LOAN APPLICATION DATAILS
Loan Amount: Loan Purpose:
LOAN TENURE 1 2 3 4 5 6 7 8 9 12 Others (Specify):
Would you like the following ZB life Cover? 6 Months: 12 months: 18 months: Other (Specify)
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:
FOR OFFICIAL USE ONLY
Received & Checked by: Name: Signature: Date:
Approved by: Name: Signature: Date:
KYC CHECKLIST
Copy of ID, Licence, Valid Passport
Current Pay Slip
Stamped 3 Months’ Bank Statement
Mobile Statements
Proof of Residence/Confirmation Letter Qupa Date Stamp:
