MMFB/CRM/01

LOAN APPLICATION FORM NEW □ EXISTING □

PASSPORT

ENTERPRISE LOAN □ MSEF □ PAYEE □ OTHERS __________________________

1. APPLICANT’S DETAILS

FULL NAME_____________________________________________________________________________________________________________________________

MEANS OF ID: INT’L PASSPORT □ NATIONAL ID □ DRIVER’S LICENSE □ OTHERS_____________________

ID NUMBER __________________ DATE ISSUED _____________________ EXPIRY DATE _________________________________

TELEPHONE NO______________ MOBILE NO.____________________ BVN.______________________________

MARITAL STATUS SINGLE □ MARRIED □ SEPARATED □ DIVORCED □

DATE OF BITRH__________________________ STATE OF ORIGIN___________________________ LGA________________________________________

EMAIL ADDRESS________________________________________________________________________________________________________________________

HOME ADDRESS________________________________________________________________________________________________________________________

LANDMARK/NEAREST BUSTOP____________________________________________________________________________________________________________

2. SPOUSAL CONSENT

NAME OF SPOUSE_________________________ DEPENDANTS_________________________________________

NUMBER OF CHILDREN _____________________________ TEL NO________________________________________________

SPOUSE BUSINESS ADDRESS____________________________________________ SPOUSE SIGNATURE____________________________________________

3. GUARANTORS DETAILS

1. ____________________________________________________________________________________________________________________________________

2. ____________________________________________________________________________________________________________________________________

4. EMPLOYMENT STATUS (PROVIDE PAYSLIP, ACCOUNT STATEMENT AND EMPLPOYER’S CONFRIMATION)

FULL TIME □ PART-TIME □ CONTRACT STAFF □ PUBLIC SERVANT □ SELF EMPLOYED □

INDUSTRY/SECTOR_____________________________ NO YEARS IN EMPLOYMENT_______________________ DATE OF FEMPLOYMENT_____________________

POSITION/FUNCTION_________________________________ DEPARTMENT__________________________________________

MONTHLY SALARY____________________________________ MONTHLY DEDUCTIONS_________________________________

CURRENT EMPLOYER NAME_______________________________________________________________________________________________________________

CURRENT EMPLOYER ADDRESS_____________________________________________________________________________________________________________

OFFICE TELEPHONE_______________________________________________________________________________________________________________________

WORK EMAIL____________________________________________________________________________________________________________________________

5. BUSINESS DETAILS (PROVIDE ACCOUNT STATEMENT)

TYPE OF BUSINESS___________________________________________________ YEARS IN BUSINESS____________________________

BUSINESS ADDRESS______________________________________________________________________________________________________________________

ASSOCIATION __________________________________________ ID NO_______________________________________

AV. MONTHLY SALES______________________________ AV. MONTHLY CREDIT T/O_______________________________________

FACILITY WITH OTHER BANKS________________________ AMOUNT_______________ TENOR___________________

FACILITY WITH OTHER BANKS________________________ AMOUNT_______________ TENOR___________________

6. EDUCATIONAL STATUS

PRIMARY □ SECONDARY □ GRADUATE □ POST GRADUATE □

7. LOAN DETAILS

LOAN PURPOSE________________________________________________________________________________________________________________________

LOAN AMOUNT_________________________________________________________________________________________________________________________

LOAN TENOR___________________________________________________________________________________________________________________________

TYPE OF SECURITY/COLLATERAL____________________________________________________________________________________________________________

MODE OF REPAYMENT: CHEQUE □ STANDING ORDER □ DIRECT DEBIT □ CASH DEPOSIT □

8. DISBURSEMENT DETAILS

ACCOUNT NAME_________________________________________________________________________________________________________________________

ACCOUNT NUMBER______________________________________________________________________________________________________________________

BANK NAME_________________________________ SORT CODE_________________________ BRANCH___________________________________

9. CONSENT TO DISCLOSE INFORMATION

I consent that the Bank may collect, use and disclose my transaction/information to any appointed Credit Bureau and that the Credit Bureau may use the information
for any approved business purposes as may from time to time be prescribed by the Central Bank of Nigeria (CBN) and/ or any relevant statute.

I authorize the Bank to conduct previous/current credit information checks on me/us from other financial institutions through any relevant means/ agency.

In the event of default, I hereby authorize Mainstreet Microfinance Bank to fill and pay in my cheque in repayment for the facility granted me by the bank.

I here execute a GSI Mandate authorizing Mainstreet Microfinance Bank to recover any amount outstanding from the principal and interest from any/all accounts
maintained by me across all Financial Institutions.

Declaration:

I hereby confirm that the above information is correct and I understand the conditions and agree to be bound by the Terms and Conditions of the loan.

APPLICANT’S SIGNATURE ____________________________________ DATE _______________________________

OFFICIAL USE ONLY

VISITATION REPORT

DATE OF VISITATION__________________________________

MET WITH____________________________________________

BRIEF DESCRIPTION OF PREMISES (TYPE OF BUILDING/STORIES, COLOUR, LANDMARK ETC)

______________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

BRIEF DESCRIPTION TO CLIENT FROM THE BRANCH

______________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

NAME OF VISITING OFFICER_____________________________________ NAME OF ACCOUNT OFFICER__________________________________________

SIGNATURE__________________________________________________ SIGNATURE__________________________________________________

BRANCH MANAGERS’ SIGNOFF/CONCURRENCE_____________________________________________________