Business Name*
Business Registration No.*
Business Registration Date* (mm/dd/yy)
Business Address*
Postal Code*
City*
Name*
Date of Birth* (mm/dd/yy)
ID/Passport No*
PIN No*
Residential Address*
Telephone (O)* +254
Telephone (R) +254
Telephone (M) +254
Email:*
Existing Client*YesNo
Home Ownership*TenantOwnerCo-Owner
Nature of Business/Profession*
Marital StatusMarriedSingleDivorcedWidowed
Spouse Name
Spouse ID
Spouse PIN
Spouse Business/Profession
Telephone (O) +254
Borrowings
Facility being applied for:
Vehicle make & Model*
Year of Manufacture (YYYY)
Total Cost*
Down payment
Finance Amount
Period for finance* ---12 Months24 Months36 MonthsOther
Dealer Name
Dealer Address
Dealer Phone
Dealer Email
Insurance Company
Insurance TypeComprehensiveTPO
Tracking Company
Input the code below*
