CREDIT CLEAR APPLICATION FORM This field is hidden when viewing the formNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page: (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020). Important: Delete this tip before you publish the form.Section 1Name(Required) First Last Email(Required) Enter Email Confirm Email Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 1.Credit Clearance: I need the following service:(Required) Debt review clearance. I paid off all my accounts and need bureau clearance assistance and I need assistance with dealing with the five major bureaus. Debt review removal. I paid some accounts. I live in Gauteng and need assistance with the court application. Debt review removal. I paid some accounts. I live outside Gauteng and need assistance and need assistance with the court application Credit Bureau Removal Tick the relevant answer below 2. Debt Review: Please select the appropriate option.(Required) I am not in debt review I am in debt review and all my debts have been settled I am in debt review and some on my accounts have been settled I am in debt review and none of my accounts have been settled Tick the relevant answer below 4. Have you been declined any credit application?(Required) Yes No Tick the relevant answer below 3. Do you have accounts which have not been paid for 3 years and you have not made any arrangement or promise to pay?(Required) Yes No Don’t know, please investigate for me Tick the relevant answer below If there are any special instructions you wish us to follow, please let us know in the box below.Section 2Application FormID Number:Names as per ID(Required)Surname as per ID(Required)Cell Phone Number(Required)Work Number(Required)Email Address(Required)Please confirm Email Address(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Employer NameGross Salary as per salary advice (payslip)(Required)Nett Salary as per salary advice (payslip)(Required)Additional IncomeSalary Frequency: Please select the frequency relevant to you.(Required)WeeklyMonthlyBi MonthlyDate on which you receive your salary. DD slash MM slash YYYY Please state the reason for this Credit Clearance Application(Required)I’m looking for vehicle financeI’m looking for Home loan financeI’m looking for a credit cardI just need a clean credit recordOther reason. If other reason, please provide a short description of your reason belowReason for Credit Clearance.Section 3Consent I hereby grant my informed consent to Prime Debt Solution to enable them to perform a confidential credit check on me for the purpose of compliance with the provisions of Section 81(2) of the National Credit Act, NO. 34 of 2005 as amended, that relates to the prevention of the extension of reckless credit. It is further understood that the credit report obtained under this consent will be used by Prime Debt Solution solely for the purpose set out in Regulation 19 (4) (c) or (e) to (g) I/We also provide consent for the processing of my/our personal information as outlined in the Protection pf Personal Information Act NO.4 of 2013. This consent is granted for the specific purpose of Prime Debt Solution in relation to my/our Debt Review Clearance and or Credit Bureau Clearance application. Our utmost priority is safeguarding your personal and confidential information, and we are dedicated to upholding this commitment in full accordance with the Protection of Personal Information Act NO.4 of 2013. Prime Debt Solution employs robust ICT security measures to guarantee this level of Protection. Users are advised that, by clicking (or submitting) on any “Submit” button on this site the user thereby submits an electronic signature, as contemplated in Section 11 of the Electronic Communications and Transactions Act.NO.25 of 2022. Such signature carries with it all the weight of all contractual and legal obligations which may arise from the submission of such signature. Authorization to Obtain Personal Information I do hereby authorize Xpert Decision Systems Pty Ltd, as a registered credit bureau, to obtain my personal information, including a copy pf my full credit report/ bank statement or any other credible evidence pertaining to my account. I know and understand that the information contained therein is of a confidential nature and hereby entrust XDS as my agent to obtain the same on my behalf. I understand that I may revoke this authorization in writing at any time except for the information already released because of this authorization and that unless revoked this authorization in writing it will remain in force on effect. I hereby certify that the following documentation has been attached hereto: 1.A copy of my identification document 2.Valid proof of residential address I confirm the above details are correct and hereby accept and give consent to Prime Debt Solution Pty Ltd to obtain a credit report in order for an assessment and consultation to be conducted. Signature Required We cannot proceed without a valid consent signature. Electronic Signature To avoid any delays in processing your application, please ensure you sign in the signature block. Users are advised that, by clicking on any” Submit” button on this site, the user hereby submits an electronic signature as contemplated in Section 11 of the Electronic Communications and Transactions Act NO.25 of 2022. Such signature carries with it all the weight of all contractual and legal obligations which may arise from the submission of such signature. Signature(Required)Date(Required) DD slash MM slash YYYY Application and Credit Bureaus Report Assessment fee. R1500.00 Fee Payment Options(Required)I will pay full fee once off via EFT Bank depositI will pay full once fee via Credit Card / DebitPower of Attorney and Fee Agreement Prime Debt Solution and their duly nominated employees with the power of substitution, to be my agents in my name, place and stead to access all my personal financial and credit information, whether telephonically or online (using my personal information) or any other means available to Prime Debt Solution will ensure the confidentiality of this information. This information will be used to be able to deal with clearing and or updating my ADVERSE Information in accordance with the National Credit Act. This include but not limited to: -Obtaining my credit reports (before and on finalisation of the process) -Obtaining outstanding balances from my creditors. -Obtaining copies of contracts and or any other documentation about alleged credit provided to me by my creditors. Providing me with proposals to remove and or update my adverse listings, obtaining paid-up letters and lodging credit bureau disputes on my behalf. Get paid-up confirmations and paid-up letters from past and current creditors and obtain any legal paperwork necessary to revoke judgments. Prepare, sign, and file documents with any governmental body and credit providers. Employ professional and business assistance as may be appropriate, including attorneys, accountants, real estate agents and bond originators. Obtain information or documents from any government or credit providers and negotiate compromise or settle any matter with such government or credit providers. I also authorise Prime Dent Solution to release any such information as may be necessary about my identity, my employment status and my financial circumstances to any other person/ institution provided that it is related and limited to my current credit status, and generally for effecting the purposes aforesaid, to do or cause to be done whatsoever shall be requisite, as fully and effectually as I might or could do if personally present and acting herein, aforesaid, to do or cause to be , done whatsoever shall be requisite as fully as I might or could do if personally present and acting herein. I undertake to confirm any actions by Prime Debt Solution in terms of this Power of Attorney should I be called upon or required to do so. Regarding Section (3) of the Protection of Personal Information Act.NO.4 of 2023 Act (POPIA), I give my consent to Prime Debt Solution providing my personal information, but not limited to my name, identity number, and account number, to my creditors. In turn, I consent to any creditors proving Prime Debt Solution with the information requested by them pertaining but not limited to balances, statements, prescription letters, paid-up letters, contracts, documents and any other information required by Prime Debt Solution should any matter that I have mandated Prime Debt Solution to deal with, become disputed. I confirm that I know the said information exchanged between Prime Debt Solution and my creditors will only be used to improve my credit status at the different credit bureaus. This Special Power of Attorney shall continue effective until my cancellation with Prime Debt Solution or by “the attorneys “nominated by Prime Debt Solution. This Power of Attorney may be revoked by me at any time by providing written notice to Prime Debt Solution. Consent- I confirm the above details are correct and hereby accept and give consent to Prime Debt Solution Pty Ltd to obtain a credit report in order for an assessment and consultation to be conducted. I agree and hereby give signed consent. SignatureDate DD slash MM slash YYYY Consent(Required)I confirm that the above information is correct and that I do consent to the above agreements. Please upload proof of residence not older than three monthsMax. file size: 10 MB.Please upload copy of IDMax. file size: 128 MB.
