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	First name Surname Cellphone   Telephone (h)   Telephone (w)   E-mail address Province Best time to contact me Total gross monthly household income (before deductions) Total monthly household deductions Total monthly household expenses (excluding salary deductions) Amount of collateral security available Deposit Bond required Your existing bank Name of Sanlam adviser or broker   How would you describe your: Credit record Select Excellent Fair Poor Banking record Select Excellent Fair Poor     clear   submit