Personal Information

First name

Last name

Birthday

Day

Month

Year

Gender

Residential Address

Phone

Bank Verification Number

Employment Details

Employment Status

Name of Employer/Business

Work Address

Monthly Income (Net)

Employment Start Date

Provide your current bank statement for the last 5 months

Vehicle Information

Vehicle Make: (e.g., Toyota, Honda, Nissan)

Year of Manufacture: (Between 2000 and 2015)

Vehicle Registration Number:

Vehicle Colour:

Chassis/VIN Number:

Fuel System: (Carburetor/Injector)

Type of Engine: (4, 6, or 8 cylinders)

Service History (if available): (Yes/No)

Mileage (km): (Optional)

Have you had your vehicle assessed for CNG conversion? (Yes/No)

If Yes, please provide the name of the Certified Conversion Center where the assessment was conducted

Do you have a referral code from a Verified Conversion Center? (Yes/No)

If Yes, please provide the code: (Insert code here)

If you have not had your vehicle assessed but would like to, please select your preferred Certified CNG Conversion Center for assessment: (Select from list)

Preferred Appointment Date: (DD/MM/YYYY)

Day

Month

Year

Loan Details

Desire Loan Amount

Preferred Loan Tenor (e.g., 12 months, 24 months)

Are you willing to provide a minimum equity contribution of 10%? (Yes/No)

Do you have a clean credit report from at least two credit bureaus? (Yes/No)

Have you ever defaulted on a loan repayment? (Yes/No)

Consent and Authorization

Do you authorize CREDICORP to share your details with Participating Financial Institutions (PFIs) for loan processing? (Yes/No)