Application Form

DETAILS OF REFERRAL

Please specify the Name and Surname of the person who referred you to The X Quotient *

First

Last

Please specify the Phone Number of the person who referred you to The X Quotient

Please indicate amount of financing required (R) *

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?

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:

25% OR MORE SHAREHOLDERS

Please complete the details of all shareholders who hold 25% or more of the shares of the company below.

Full Name & Surname

Shareholder 1 Details

Full Name & Surname

Shareholder 2 Details

Full Name & Surname

Shareholder 3 Details

Full Name & Surname

Shareholder 4 Details

ID Number

Percentage Holding

Please enter percentage.

Percentage Holding

Please enter percentage.

Percentage Holding

Please enter percentage.

Percentage Holding

Please enter percentage.

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 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 *

Purchase Order Number *

Purchase Order Expiry 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 *

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 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.

Terms & Conditions

Please read through all important information and confirm below. (Link to privacy policy at bottom of page). *

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

Layout

Application: purchase

order finance.

Application: Purchase Order Finance.

Please only fill out this form if you were referred to The X Quotient by a particular person. If you were not referred by anyone, please fill out the form on this page: https://thexquotient.com/application-form/

DETAILS OF REFERRAL