Loan Form

PERSONAL DETAILS

Title *

MR
MRS
MASTER
MISS

NAME (Surname) *

NAME (First Name) *

NAME (Middle Name) *

NATIONAL IDENTIFICATION NUMBER (NIN)

EMERGENCY CONTACT NUMBER *

DATE OF BIRTH (DD/MM/YYYY) *

GENDER *

Male
Female

NATIONALITY *

Nigerian
Others (Specify)

PLEASE SPECIFY COUNTRY *

MARITAL STATUS *

Single
Married

LOCAL GOVERNMENT AREA *

STATE OF ORIGIN *

MEANS OF IDENTIFICATION

Means Of Identification *

NATIONAL I.D CARD
NATIONAL DRIVER'S LICENCE
INT'L PASSPORT
VALID INEC VOTERS CARD
OTHERS (SPECIFY)

Specify Other Means Of ID *

I.D NUMBER *

I.D ISSUE DATE (DD/MM/YYYY) *

I.D EXPIRY DATE (DD/MM/YYYY) *

BANK VERIFICATION NUMBER (B.V.N) *

RESIDENTIAL ADDRESS

HOUSE NUMBER *

STREET NAME *

CITY/TOWN *

NEAREST BUS STOP/LANDMARK *

L.G.A *

STATE *

Email *

Confirm Email

PHONE NUMBER *

SIGNATURE (UPLOAD)

SIGNATURE *

Use full name as a signature.

DATE (DD/MM/YYYY) *

USE THE SPACE BAR to go to the next option.

TYPE OF LOAN

Loan Type

Business Loan
Salary Loan

REQUEST AMOUNT (Naira) *

TENOR

PURPOSE *

BUSINESS DATA

BUSINESS NAME

NATURE OF BUSINESS

FULL TIME OR PART TIME *

Full Time
Part Time

BUSINESS ADDRESS

HOUSE NUMBER/PLOT *

STREET NAME *

NEAREST BUS STOP/LANDMARK *

L.G.A *

CITY/TOWN *

STATE *

OTHERS

BUSINESS COMMENCEMENT DATE (DD/MM/YYYY) *

MONTHLY SALES (PEAK PERIOD)

MONTHLY SALES (OFF PEAK PERIOD)

NET PROFIT MONTH *

Outstanding Indebtedness to Banks/F.Is

ACCOUNT NUMBER *

NAME OF BANK *

BANK ADDRESS *

I agree to the terms and conditions attached to this loan and hereby authorize Quantum Intervention to effect necessary action to recover the loan and accrued interest in the event of default.

RESPONSE *

SIGNATURE (UPLOAD - Optional)

SIGNATURE *

Use full name as a signature. USE THE SPACE BAR to go to the next option.

DATE (DD/MM/YYYY) *

USE THE SPACE BAR to go to the next option.

REQUEST AMOUNT (Naira) *

TENOR

PURPOSE *

EMPLOYMENT DATA

EMPLOYER'S NAME *

TERMS OF EMPLOYMENT

FULL TIME OR PART TIME (SALARY) *

Full Time
Part Time

EMPLOYMENT STATUS *

Confirmed
Unconfirmed

GRADE/JOB LEVEL *

EMPLOYER'S ADDRESS

OFFICE NO *

STREET NAME *

NEAREST BUS STOP/LANDMARK *

L.G.A *

CITY/TOWN *

STATE *

OTHERS

APPOINTMENT DATE (DD/MM/YYYY) *

GROSS INCOME PER ANNUM *

NET PAY PER MONTH *

PAY DATE/DATE OF SALARY PAYMENT (DD) *

ACCOUNT NUMBER *

NAME OF BANK *

BANK ADDRESS

I agree to the terms and conditions attached to this loan and hereby authorize Quantum Intervention to effect necessary action to recover the loan and accrued interest in the event of default.

RESPONSE. *

SIGNATURE (UPLOAD)

SIGNATURE *

Use full name as a signature. USE THE SPACE BAR to go to the next option.

DATE (DD/MM/YYYY) *

USE THE SPACE BAR to go to the next option.

GUARANTOR'S FORM

GUARANTOR 1

NAME (Surname) *

NAME (First Name) *

NAME (Middle Name) *

ADDRESS *

OCCUPATION *

RELATIONSHIP TO APPLICANT *

FIRST GUARANTOR'S PHONE NUMBER *

FIRST GUARANTOR'S EMAIL *

SIGNATURE *

Use full name as a signature. USE THE SPACE BAR to go to the next option.

DATE (DD/MM/YYYY) *

USE THE SPACE BAR to go to the next option.

GUARANTOR 2

NAME (Surname) *

NAME (First Name) *

NAME (Middle Name) *

ADDRESS *

OCCUPATION *

RELATIONSHIP TO APPLICANT *

SECOND GUARANTOR'S PHONE NUMBER *

SECOND GUARANTOR'S EMAIL *

SIGNATURE *

Use full name as a signature. USE THE SPACE BAR to go to the next option.

DATE (DD/MM/YYYY) *

USE THE SPACE BAR to go to the next option.

LOAN UNDERTAKING

I hereby undertake to submit the following underlisted documents as security for the loan applied for in your company:

DOCUMENTS (Upload)

Select Document 1

Select Document 1

Specify what type of document

Upload Document 1

Select Document 2

Select Document 2

Specify what type of document

Upload Document 2

Select Document 3

Select Document 3

Specify what type of document

Upload Document 3

The aforementioned security items submitted are to be used to defray my outstanding indebtedness and applicable charges in the event of default. In addition, I also undertake to pay default or penal charges (as may be applied) for any monthly repayment default.

Yours faithfully,

SIGNATURE *

Use full name as a signature.

DATE (DD/MM/YYYY) *

Enter the day, month, year and submit.

Loan Form

PERSONAL DETAILS

MEANS OF IDENTIFICATION

RESIDENTIAL ADDRESS

TYPE OF LOAN

BUSINESS DATA

BUSINESS ADDRESS

OTHERS

EMPLOYMENT DATA

EMPLOYER'S ADDRESS

OTHERS

GUARANTOR'S FORM

GUARANTOR 1

GUARANTOR 2

LOAN UNDERTAKING

DOCUMENTS (Upload)

ABOUT US

CONTACT INFO

ADDRESS

QUICK LINKS

Quantum Agent