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TRIVISTA CAPITAL LIMITED Insert a current passport photograph CONSUMER FINANCE APPLICATION FORM A. PERSONAL INFORMATION Surname Other names Dr. /Mr. /Mrs. /Miss Marital Status Married Single / Sex Male Female / Age Means of Identification International passport Drivers License National ID Card Residential Address P. O Box not allowed Tel Home Mobile Phone Present Employer Name Address Position at work Department Beneficiary s work e-mail Next of kin Address Next of kin phone House Mobile Bank Details Your Bank details are required to process your loan application* Please note that the information provided is strictly for the loan purpose. Do you currently have a Bank account Yes No Bank Name Account number B. LOAN REQUEST Amount N Amount in words Proposed Tenor Loan Purpose Repayment Source Repayment Method Direct Debit Post Dated Cheques Bank Standing Order Security proposed C. DECLARATION and certify that all information provided by me above and attached hereto is correct and complete. I authorize you to make any enquiry you consider necessary and appropriate for the purpose of evaluating this application* I also undertake to repay/liquidate all sums granted to me as loan in addition to the interest. I am also aware of the implication of dishonoured cheque act DCA of 1977 no 44 CAP. D11 amended to date. Attached to this form is a copy of my valid employer endorsed identity card. Signature of borrower Date. /Mr. /Mrs. /Miss Marital Status Married Single / Sex Male Female / Age Means of Identification International passport Drivers License National ID Card Residential Address P. O Box not allowed Tel Home Mobile Phone Present Employer Name Address Position at work Department Beneficiary s work e-mail Next of kin Address Next of kin phone House Mobile Bank Details Your Bank details are required to process your loan application* Please note that the information provided is strictly for the loan purpose. O Box not allowed Tel Home Mobile Phone Present Employer Name Address Position at work Department Beneficiary s work e-mail Next of kin Address Next of kin phone House Mobile Bank Details Your Bank details are required to process your loan application* Please note that the information provided is strictly for the loan purpose. Do you currently have a Bank account Yes No Bank Name Account number B. LOAN REQUEST Amount N Amount in words Proposed Tenor Loan Purpose Repayment Source Repayment Method Direct Debit Post Dated Cheques Bank Standing Order Security proposed C. Do you currently have a Bank account Yes No Bank Name Account number B. LOAN REQUEST Amount N Amount in words Proposed Tenor Loan Purpose Repayment Source Repayment Method Direct Debit Post Dated Cheques Bank Standing Order Security proposed C. DECLARATION and certify that all information provided by me above and attached hereto is correct and complete. DECLARATION and certify that all information provided by me above and attached hereto is correct and complete. I authorize you to make any enquiry you consider necessary and appropriate for the purpose of evaluating this application* I also undertake to repay/liquidate all sums granted to me as loan in addition to the interest.

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