PERSONAL LOAN 0793873907-James

APPLICATION FORM
Branch: Nyamira Date: D D M M Y Y Y Y

Applicant’s Co-op Bank Account Number (If Any)

Teachers Service Commission

Name of the Employer: _____________________________________________________________________________________________________

PERSONAL DETAILS

Salutation: Mr. Mrs. Ms. Miss Dr Prof.

First Name:______________________________ Middle Name: ___________________________ Last Name: _______________________________

National ID/ Passport Number: Personal File Number/Force Number: Date of Birth: D D M M Y Y Y Y

Marital Status: Single Married Widowed Separated

Mobile Number: Email Address:

Home Postal Address: Postal Code: Town:

Residential Status: Owner: Tenant: Living with Parents: Housed by Employer: Other (Specify):

If tenant state rental amount:

Current Residential Area/ Estate: Town: Duration in current residence (Years):

If duration at current residence is less than 5 years state previous Residential Area/ Estate: Town:

REFEREE DETAILS

NEXT OF KIN PERSONAL REFEREE (Not a relative)

Full Name:

Relationship: Workmate

National ID/ Passport/ Service Number:

Address:

Telephone Number:

EMPLOYER DETAILS

Current Station/Department: Office Tel. Number:

Employer Address: Postal Code: Town:

Employment Date: Maximum Retirement Age:

Are you a director and or related to anyone in the Bank? Yes No If yes give details below:
Name Relationship

LOAN REQUEST

I (Name of borrower): ______________________________________________________________ hereby apply for a loan of Kes (figures): ___________________________

Amount in words:_____________________________________________________________________________________________________________________________
development
Purpose of loan:__________________________________________________________ Duration: ____________________Monthly Installments ______________________

MOBILE BANKING ALERTS SUBSCRIPTION

Mobile Phone Number: + 2 5 4 0

Alerts to Activate (Tick Appropriately): All Credits All Debits

Customer Signature__________________________________ 8802

DSO code__ ______________ ARO code_________________
080PB01
 PERSONAL LOAN
APPLICATION FORM
BORROWER’S DECLARATION

1. I hereby declare that the foregoing particulars are true. I have not entered into a separate agreement with any entity not disclosed, including the Bank for a personal loan
based on my salary. There has not been any fact, event or circumstance that, alone when taken with other events or conditions has a material adverse effect on my
employment.
2. I agree that the loan and my obligations to the Bank under the terms and conditions shall be effective immediately upon the Bank approving the sum applied for or as
may be determined by the Banks subject to any security requirement as a condition precedent by crediting or applying the same to
my account with the Bank or otherwise for my account. In consideration of the Bank agreeing to grant me the loan applied for or such lower sum, at
such interest cost, and the terms and conditions set out in this application.
i. If the loan is to be repaid via check off: I hereby request and irrevocably authorize my employer_____________________________________ to deduct monthly
from my salary the principle, interest and costs as all advised by the Bank and remit the same to the Bank for such period as the Bank shall advise from time to time.
ii. If the loan is to be paid via a standing order: hereby authorize and instruct the Bank to debit my account number _____________________________
with the Bank with Kes _________________ (Amount in words) _________________________________________________________________ or such other sum
as will be required by the Bank to meet the approved monthly loan repayment and to pay into the loan account on the __________of every month effective
30 days after the loan has been disbursed.
3. For as long as any such loan shall be outstanding, I hereby assign all my final terminal dues excluding pension of whatsoever nature with my
employer____________________________________________ to the Bank as additional security for the payment of the loan, and any balance upon such payment, to be
credited by the Bank to my account with the Bank and accordingly hereby request and authorize my said employer to pay out the said dues to the Bank whenever they
become due and payable unless otherwise advised by the Bank.
4. The Bank may grant me lesser loan than that applied for and that my obligations herein and under such terms shall be effective immediately upon the Bank crediting my
account with such loan sum.
5. I agree that I will personally remain liable to pay any installment of the loan and the entire loan notwithstanding any delay or failure by my employer to deduct and/ or
remit the payments to the Bank or any insufficiency thereof.

Signed by the Applicant: ________________________________________________________ this ______________day of ____________ 20________

Witness Name: __________________________________________________Signature______________________________ Date__________________

CONFIRMATION BY EMPLOYER

I confirm that the Borrower is an Employee of (name of employer) ___________________________________________________________and that the employment details
given above are true and confirm having noted the instructions/ request to deduct and pay monthly payments from the employee’s monthly salary, and hereby take notice of
the assignment of all the final terminal dues excluding pensions to the Bank.
I recommend/ do not recommend this loan application; (give reasons if not recommended).______________________________________________________________

Employer Officer’s Name: _________________________________Designation: ___________________________

Sign&Stamp: _______________________________________________________ Date: _________________________ Contact ..........................

OFFICIAL STAMP:

CREDIT LIFE INSURANCE

I forfeit my right to choose an Insurance Service Provider and Agency and consent to the use of CIC Life Assurance Company & Co-op Consultancy Insurance Agency Limited
as the providers of my Credit Life Insurance on my loan in the event of the covered risk subject to the terms and conditions of the insurance policy.

Yes I do
No I don’t
If Not: Indicate name from the IRA website link (www.ira.go.ke)

_________________________________________________________________________________________________________
NB: Credit Life Insurance can be found in Co-operative Bank of Kenya website: https://bit.ly/2W5hrTm

TERMS AND CONDITIONS

I (name of borrower) _______________________________________________________ of P.O. Box __________________________ hereby acknowledge that I have read,
understood and accepted Terms and Conditions as hosted in Co-operative Bank website; https://bit.ly/2W5hrTm, and I confirm my intention to be bound by them.

Customer Signature: __________________________________________________________ Date: ___________________________________

Witness Name: ____________________________________________ Witness Signature: ______________________ Date: _______________

Signed For The Bank

By:____________________________________________________________________________________________________________________________________

Signature:__________________________________________ Signature Number: __________________________________ Date: ____________________________

Customer Signature__________________________________ 8802

DSO code__ ______________ 080PB01
ARO code_________________
Co-operative Bank House Haile Selassie Avenue | P.O BOX 48231, 00100,
NAIROBI TEL: +254 020 327 6000 or 0703 027 000, Whatsapp: 0736690101
EMAIL: [email protected]