Funding Form | Umsebenzi Capital

Please indicate amount of financing required (R)

Minimum Price: R100,000.00

Which funding option are you applying for?

BUSINESS INFORMATION

Company Name

Company Registration Number

Company Type

Business Number

Business Email Address

Email

Confirm Email

VAT Number

Income Tax Number

Date Business Commenced:

Business Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Postal Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

How long have you been at this address?

5% OR MORE SHAREHOLDERS

Please complete the details of all shareholders who hold 5% or more of the shares of the company below.

Full Name & Surname

Shareholder 1

ID Number

Shareholder 1

Percentage Holding

Shareholder 1: Please enter percentage.

Full Name & Surname

Shareholder 2

ID Number

Shareholder 2

Percentage Holding

Shareholder 2: Please enter percentage.

Full Name & Surname

Shareholder 3

ID Number

Shareholder 3

Percentage Holding

Shareholder 3: Please enter percentage.

Full Name & Surname

Shareholder 4

ID Number

Shareholder 4

Percentage Holding

Shareholder 4: Please enter percentage.

DIRECTORS OF THE COMPANY

If you have more than 4 directors in your company, please email us at pieter@thexquotient.com

Please indicate the number of directors in the company:

PERSONAL CONTACT INFORMATION - DIRECTOR 1

Title

Director 1

Full Names

Director 1

Surname

Director 1

Country of Citizenship

Director 1

ID/Passport Number

Director 1

Residential Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Director 1

Postal Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Director 1

Cell Phone Number

Director 1

Email Address

Email

Confirm Email

Director 1

Marital Status

Director 1

Marriage Type

Director 1

Please provide your spouse's full name and surname:

Director 1: Married - In Community of Property

Please provide your spouse's ID number:

Director 1: Married - In Community of Property

Please provide your spouse's email address:

Director 1: Married - In Community of Property

Please provide your spouse's phone number:

Director 1: Married - In Community of Property

Have you ever been declared insolvent / sequestrated?

Director 1

Please provide more information.

Director 1

Are you or any of your immediate family members employed by any governmental body?

Director 1

Please provide more information.

Director 1

PERSONAL CONTACT INFORMATION - DIRECTOR 2

Title

Director 2

Full Names

Director 2

Surname

Director 2

Country of Citizenship

Director 2

ID/Passport Number

Director 2

Residential Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Director 2

Postal Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Director 2

Cell Phone Number

Director 2

Email Address

Email

Confirm Email

Director 2

Marital Status

Director 2

Marriage Type

Director 2

Please provide your spouse's full name and surname:

Director 2: Married - In Community of Property

Please provide your spouse's ID number:

Director 2: Married - In Community of Property

Please provide your spouse's email address:

Director 2: Married - In Community of Property

Please provide your spouse's phone number:

Director 2: Married - In Community of Property

Have you ever been declared insolvent / sequestrated?

Director 2

Please provide more information.

Director 2

Are you or any of your immediate family members employed by any governmental body?

Director 2

Please provide more information.

Director 2

PERSONAL CONTACT INFORMATION - DIRECTOR 3

Title

Director 3

Full Names

Director 3

Surname

Director 3

Country of Citizenship

Director 3

ID/Passport Number

Director 3

Residential Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Director 3

Postal Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Director 3

Cell Phone Number

Director 3

Email Address

Email

Confirm Email

Director 3

Marital Status

Director 3

Marriage Type

Director 3

Please provide your spouse's full name and surname:

Director 3: Married - In Community of Property

Please provide your spouse's ID number:

Director 3: Married - In Community of Property

Please provide your spouse's email address:

Director 3: Married - In Community of Property

Please provide your spouse's phone number:

Director 3: Married - In Community of Property

Have you ever been declared insolvent / sequestrated?

Director 3

Please provide more information.

Director 3

Are you or any of your immediate family members employed by any governmental body?

Director 3

Please provide more information.

Director 3

PERSONAL CONTACT INFORMATION - DIRECTOR 4

Title

Director 4

Full Names

Director 4

Surname

Director 4

Country of Citizenship

Director 4

ID/Passport Number

Director 4

Residential Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Director 4

Postal Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Director 4

Cell Phone Number

Director 4

Email Address

Email

Confirm Email

Director 4

Marital Status

Director 4

Marriage Type

Director 4

Please provide your spouse's full name and surname:

Director 4: Married - In Community of Property

Please provide your spouse's ID number:

Director 4: Married - In Community of Property

Please provide your spouse's email address:

Director 4: Married - In Community of Property

Please provide your spouse's phone number:

Director 4: Married - In Community of Property

Have you ever been declared insolvent / sequestrated?

Director 4

Please provide more information.

Director 4

Are you or any of your immediate family members employed by any governmental body?

Director 4

Please provide more information.

Director 4

BANK DETAILS

Bank Name

Branch Code

Account Number

Type of Account

Details of all Current Loans or Sureties

Is the company currently involved in or have any pending litigation against it?

Is the company under Business rescue or intend entering Business rescue proceedings in the next 3 months?

PURCHASE ORDER OR INVOICE DISCOUNTING TRANSACTION INFORMATION

Procuring Entity

Physical Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Cell Phone Number

Email Address

Email

Confirm Email

Purchase Order Value / invoice Value

Purchase Order Number / Invoice Number

Purchase Order Expiry Date / Invoice Date

Have you supplied this customer before?

Have you been to the customer’s premises?

DOCUMENTATION REQUIRED

Company Registration Documentation - CIPC COR14.3 or CK2 (Not older than ONE month)

Click or drag a file to this area to upload.

Certified Copies of all Director’s ID’s (Not older than 3 months)

Click or drag files to this area to upload. You can upload up to 4 files.

FICA proof of residence for Directors (Not older than 3 months)

Click or drag files to this area to upload. You can upload up to 4 files.

FICA proof of residence for the Company (Not older than 3 months). Bank Statement etc.

Click or drag files to this area to upload. You can upload up to 4 files.

SARS Tax clearance certificate – Company and Individuals

Click or drag a file to this area to upload.

If applicable, proof of CSD Summary Registration (Not older than ONE month)Report

Click or drag a file to this area to upload.

Copies of Purchase Orders including full item specifications.

Click or drag files to this area to upload. You can upload up to 10 files.

Copies of Supplier quotes/invoices for goods to be supplied.

Click or drag files to this area to upload. You can upload up to 10 files.

Bank Account Confirmation Letter

Click or drag files to this area to upload. You can upload up to 10 files.

Please attach a selfie of each director holding their ID document next to their face. Please make sure both the face and ID details are clearly visible.

Click or drag files to this area to upload. You can upload up to 10 files.

HOW DID YOU HEAR ABOUT US?

Please Specify

Name & Surname of the Friend/Colleague that referred you:

Other: Please Specify

Terms & Conditions

Please read through all important information and confirm below.

I have read and understand the Declaration, Authority to Conduct Credit Search and the Privacy Policy below.

APPLY FOR FUNDING

Apply for

Funding

Application form

BUSINESS INFORMATION

5% OR MORE SHAREHOLDERS

DIRECTORS OF THE COMPANY

PERSONAL CONTACT INFORMATION - DIRECTOR 1

PERSONAL CONTACT INFORMATION - DIRECTOR 2

PERSONAL CONTACT INFORMATION - DIRECTOR 3

PERSONAL CONTACT INFORMATION - DIRECTOR 4

BANK DETAILS

PURCHASE ORDER OR INVOICE DISCOUNTING TRANSACTION INFORMATION

DOCUMENTATION REQUIRED

HOW DID YOU HEAR ABOUT US?

Terms & Conditions

AUTHORITY TO CONDUCT CREDIT SEARCH

Funding Solutions

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Funding Solutions

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