Name *

First Name

Last Name

Preferred method of contact

Email

Phone

Phone

(###)

###

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POPI *

I, being of sound mind am fully aware of my rights to privacy in terms of section 14 of the Constitution 1996 and in terms of the Protection of Personal Information Act, 2013 (as amended) (“POPI’’), and for purposes of establishing my financial position, do hereby consent, as contemplated in Section 1 of POPI, to my financial and personal information being disclosed to UsPlus Limited including but not limited to information or data kept on me by credit agencies, banks, professional bodies, trade debtors and landlords of premises that I have rented, on condition that the financial information disclosed remains confidential in the hands of the UsPlus Limited, and is to be destroyed if at any time I should withdraw this authorisation in writing. I specifically agree to indemnify UsPlus and hold it harmless against any and all claims whether contingent, actual, pre-existing, or not which may be lodged against UsPlus as a consequence of its actions pursuant to this consent. I am also authorised to give all the information provided above on this form.

Yes

No