| Name of Group or CBO: |
Photo of Applicant |
Address:
|
Name of Individual Applicant:
|
| Age: |
Gender: Male / Female |
No. of Dependants: |
Name of Next of kin: |
| Education level (circle one): Primary / Secondary / Teacher Training / Other |
Physical Address:
|
| Parish: |
Sub-county: |
County: |
| Name of Enterprise Activity: |
Location of Enterprise Activity: |
| Applicant's Experience in Enterprise Activity(years) |
| Name & nature of any other types of business or trade in which applicant is occasionally engaged: |
| Other sources of income: |
| Indicate loan requirements (budget): |
| Personal Contribution (equity): |
| Amount of own savings in group account (shillings): |
Own Savings Account No. |
| Balance on Account (shillings) |
Bank: |
| Have you borrowed money from friends, relatives or bank? . No or Yes (circle one) |
| If yes, amount (shillings) |
From |
| Outstanding Balance (shillings) |
| When is the loan required |
| 1st: |
2nd: |
| 3rd: |
4th: |
I plan to repay the loan in __________________ months in equal instalments with interest thereon.
Security for the Loan:
As security for the loan, I pledge my savings with the ____________________________________________________________________ Bank/Group, and ____________________________________________________________________ (other
assets). |
Guarantors: (Trust Group)
We
the undersigned members of the Trust Group hereby confirm that the above
information is true and in our assessment the applicant is able to service
his/her loan. We further guarantee this loan and pledge our savings in
support of this Guarantee. We have fully read and understood the rules
and regulations of this scheme. In case of default, we the undersigned
pledge to pay this loan and accrued interest in full. |
|
Name |
Sex |
Age |
Position |
Amt. of Savings |
Signature |
Date |
| 1 |
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| 2 |
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| 3 |
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| 4 |
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| 5 |
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| 6 |
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| 7 |
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I, ____________________________________________________,
hereby certify that I have not failed to disclose any information which
might influence the ________________________________________________
Group in granting me the loan. I further declare that the information given
herein is true. I understand that the
completion of this form does not entitle me to a loan.
Signature of Applicant: _____________________ Date: __________________ |
| Group Confirmation and Recommendations: |
| We
members of the _______________________________________________ Group hereby certify that
the application and the individuals in the Trust Group are members of this
group and that the group committee decided as follows: |
| Recommended |
Rejected |
Deferred |
|
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| If recommended, |
| Amount (shillings) |
Repayment Period |
Instalments (Shillings) |
|
|
(Monthly or Quarterly) |
| Signed: |
| Title: |
Chair Person |
Secretary |
Treasurer |
| Name: |
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| Signature: |
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