ACB - CUSTOMER’S CONSENT FORM

REQUEST FOR CREDIT FACILITIES

Details of Applicant(s)
Surname: First Name:

1. 1.

2. 2.
Address Identification:
 ID
 DP
 PP
Date of Birth

Total Amount Requested:

Purpose:

In consideration of the request for credit facilities in the above named

applicant(s) I/we authorise you to obtain further information on my/our
credit and employment history and any such source is hereby
authorised to provide the requested information. You are authorised
to disclose to any Credit Bureau and other credit grantors any
information about my/our credit history. I/we agree to jointly and
severally indemnify you against any and all claims in damages or
otherwise arising from such authorised disclosure on your part.

Date: ___________ Signature: ______________________

*Applicant / Guarantor

Signature: _______________________
*Applicant / Guarantor

Signature: _______________________
*Applicant / Guarantor

* Delete as applicable

A 33 (11/14)