Application: purchase

order finance.

Application: Purchase Order Finance

fill out the form

APPLICATION: PURCHASE ORDER FINANCE

Please indicate amount of financing required (R) *

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

Full Names *

Surname *

Country of Citizenship *

ID/Passport Number *

Residential 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

Cell Phone Number *

Email Address *

Confirm Email

Marital Status *

Have you ever been declared insolvent / sequestrated? *

BUSINESS CONTACT INFORMATION

Company Name *

Company Registration Number *

Company Type *

Business Number

Business Email Address

Confirm Email

VAT Number

Income Tax Number

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

Date Business Commenced: *

How long have you been at this address?

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 *

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.

HOW DID YOU HEAR ABOUT US?

Please Specify

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.

DECLARATION

✔ I/We, the signatories hereby declare that the information provided by ourselves are true and correct at the time of completing the above.

✔ I / We declare that I/we have the necessary authority to transact on behalf of the company.

AUTHORITY TO CONDUCT CREDIT SEARCH

✔ By submitting this application, the signatories authorize The X Quotient (Pty) Ltd to request information concerning the company and all its directors and or shareholders from any credit bureau, or from any other credit provider, for The X Quotient (Pty) Limited to conduct a credit assessment or ongoing risk assessment in respect of the financial and credit standing, and/or conduct a trace on any of the parties. The signatories further warrant that all directors, shareholders and or members have consented in writing to such credit enquiries on the company and its directors, shareholders and or members credit profiles.

✔ The signatories further authorize The X Quotient to contact Procuring Entities to verify Purchase Orders and Invoices and make enquiries with proposed Suppliers to determine the suitability of quotes supplied, and make inquiries into the banking and business/trade references supplied.

PRIVACY POLICY

✔ By submitting this application form, I expressly consent to the processing of my personal information by The X Quotient (Pty) Ltd and I agree to have my personal information accessed and verified by third parties for purposes of this application in accordance with the privacy policy at www.thexquotient.com/privacypolicy.

✔ I indemnify and hold The X Quotient (Pty) Ltd harmless in respect of any claims by any other person against The X Quotient (Pty) Ltd, on whose behalf I have consented, should they claim that I was not so authorized.

✔ I will not hold The X Quotient (Pty) Ltd responsible for any improper or unauthorized use of personal information that is beyond its reasonable control.

Application: purchase

order finance.

Application: Purchase Order Finance

Directors of the Company

PERSONAL CONTACT INFORMATION - DIRECTOR 1

PERSONAL CONTACT INFORMATION - DIRECTOR 2

PERSONAL CONTACT INFORMATION - DIRECTOR 3

PERSONAL CONTACT INFORMATION - DIRECTOR 4

BUSINESS CONTACT INFORMATION

BANK DETAILS

PURCHASE ORDER TRANSACTION INFORMATION

DOCUMENTATION REQUIRED

HOW DID YOU HEAR ABOUT US?

Terms & Conditions

DECLARATION

AUTHORITY TO CONDUCT CREDIT SEARCH

PRIVACY POLICY

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