It is your right to access a report on your information annually for free if you come to view.
DATE:……………………………………………
Section A
Personal Details
Your Credit Data CRB Account Number:…………………………………………………
(If you do not have, please consult your financial institution you have dealt with before)
Surname ……………………………………………………………………………………
First name ………………………………………………………………………………….
Middle name(s) …………………………………………………………………………….
Maiden Name (For married women) ……………………………………………………………….
FM
Sex
Date of Birth ……………………………………………………………………………….
Marital Status……..Single Married Widowed Divorced Separated
Nationality……………………………………………………………………......
ID Type ……………………….…………ID No …………………………………………
(Please attach a copy of your ID in appendix A, ID photo attachment, page 5)
Current Postal Address ……………………………………………………………………
Current Physical Address …………………………………………………………………
………………………………………………………………………………………………
(Please attach evidence of same. e.g. utility bill)
Home address………………………………………………………………………………
Village………………………………………………………………………………………
Traditional Authority/Senior Chief………………………………………………………...
District……………………………………………………………………………………..
Tel ……………………………………… Cell …………………………………………...
Fax ……………………………………… E-mail…………………………………………
Section B
Professional Details
Name of undergraduate Institution attended in Malawi………………………………….
……………………………………………………………………………………………
Profession……………………………………………………………………………..…
Current Occupation ……………………………………………………………………..
Current Employer ……………………………………………………………………….
Address ………………………………………………………………………………….
Year of Employment ……………………………………………………………………
Last Employers Name (1) ………………………………………………………………
Address …………………………………………………………………………………
Year Left……………………………………………………………………………......
Last Employers (2)……………………………………………………………………..
Address …………………………………………………………………………………
Year Left ………………………………………………………………………………..
Section C
Additional Details
Last date of requesting a report ………………………………………………………………………………………………
Reason for request(Please tick where appropriate) Annual request
Denied credit facility
Other (please specify)……………………………………………………………………..
Section D
Secret Questions (Please respond to a minimum of 2 questions)
(d1)Please indicate your previous Physical Address………………………………………
………………………………………………………………………………………………
(d1.1)No of years at previous physical address……………………………………………
(d2)Please indicate one Institution you have an arranged borrowing (obligation)
………………………………………………………………………………………………
(d3)Please indicateyour last Employment Position …………………………………OR
(d3.1) Please indicate the Registration Number of your business…………….& date registered.
……………………………………………………………………………………………....
Please, write a secret question and an answer that will be known by only you. This will be for future reference.
Example of secret question can be “when did I buy my first car?”
Question…………………………………………………………………………………….
Answer……………………………………………………………………………………...
MODE OF REPORT DESPATCH
Postal, View
If Mail indicate Postal Address………………………………………………………..
(Please arrange for registered mail with Post Office)
…………………………………………………………………………………………
Viewing(We shall notify you the date of viewing)
Collection(Please bring your identity when collecting)
If to be printed
Please Indicate mode of payment made………………………………………………..
(If Airtel money # (+265) 0994 535 669
Mpamba # (+265) 0 882 558 063
NBS Bank a/c #.0025342777093, Credit Data, Ginnery Corner Branch)
Please indicate proof of payment……………………………………………………….
If you prefer other mode of dispatch please indicate below by describing the mode
……………………………………………………………………………………………
……………………………………………………………………………………………
Mode of request Fax Mail Telephone Email Website Hand Delivery
I declare that information provided is true and correct to my best knowledge.
Signature …………………………………..Date………………………….
Thumb Print (Witness)…………………………………………………………………..
Credit Data CRB reserves the right to accept mode of preferred dispatch and will not be held liable in whatsoever manner with regard to provision of the Report.
For Office Use Only
Received By (Name) ………………………………… Signature …………………………… ……
Reference Number…………………………………………………………………………………..
Identification verified by (Name)……………………………Signature……………………………
Payment confirmed by (Name)……………………………Signature………………………………
Approved Not Approved
Appendix A
ID photo attachment.
Situated in Phekani House, Along Glyn Jones Road, Opposite Chibisa Building, Blantyre.
PO Box 32153, Chichiri Blantyre 3. Tel: 01 831 388 Email:
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