Application FormAPPLICATION FOR PURCHASE ORDER FINANCE Company InformationCompany NameRegistrationVATSector- Select -ConstructionICTLogisticsMiningNumber Of Employees- Select -1-1010-5050-100100-200200-500500+Years of Operation- Select -1-3 years3-5 years5+ yearsContract Details Contact PersonDesignationWork NumberMobile NumberEmail AddressPurchase Order & Buyer DetailsPurchase Order NumberPurchase Order DescriptionAmountBuyerPayment TermsBuyer Details( for Verification Purposes)Contact PersonPosition in Company Phone Number Email AddressHow many contracts have you previously completed for this buyer? Have you had any previous disputes with this buyer? - Select -YesNoFunding Requirements RequestFunding Amount Required Term of Funding Required- Select -1 year2-4 years5+ yearsUse of FundsSecurity and CollateralAre you willing to provide personal guarantees/surety? Yes NoAre you willing to give us access to your business bank account transactions? Yes NoLexis WinDeed Account Holder InformationAccount NameUser NameEmail AddressPhone NumberIndividual Information (Applicant)First NameLast NameMaiden SurnameDate of BirthSA ID NumberPassportPhysical AddressLegal Authorization (Use of Data / Indemnity)"I/we hereby authorize the Account Holder / LexisNexis Risk Management (Pty) Ltd ("LNRM") to forward my/our personal/company information to credit bureaus... I/we authorize LNRM to conduct all credit checks... and unconditionally indemnify LNRM against any liability."legal authorization Submit Form
