I confirm that:
(a) I am not a minor.
(c) I am not subject to an Administration Order.
(d) I do not have any current application pending for debt restructuring or alleviation.
(e) I do not have any current debt re-arrangement in existence.
(f) I have not previously applied for a debt re-arrangement.
(g) I do not have applications pending for credit, nor open quotations as envisaged in section 92 of the National Credit Act.
If any of the above is incorrect, state which and give details:
I would like to be included in any Telemarketing Campaign
I would like to included in any marketing list that you may sell or distribute
I would like to included in any mass distribution of emails or SMS messages
* I understand that I will be liable for a monthly service fee.
* I hereby consent to this Credit Provider making enquiries regarding my credit history with any credit bereau.
* I consent to this Credit Provider reporting the conclusion of any credit agreement with me to the National Loans Register in compliance with this Credit Provider's obligation under the National Credit Act.
* I hereby declare that the information provided by me is true and correct.
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