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First name


Town / Area / Province


Cell no

Email address

Number of bathrooms in home

Bank Name


Monthly income after mortgage, car payments, other direct debits (Rands Approx.)

I require a system of

Other names

ID number


Electricity Monthly bill in excess of (insert approx. Rand figure)

Number of occupants in home (normally)

Number of electrical geysers

Account Number

Sort Code (if known)

Employed/ self employed/ retired/unemployed

Installer Company Name (if know)

 I hereby confirm that the above information is accurate, and that I agree to credit checking being undertaken, and will make available my last 3 months banks statements. I understand that PAYGS may decline my application with no reason provided. If this is completed on line my electronic submission is confirmation of the above. I understand that by completing this application form there is no obligation of my commitment to proceed

Please forward me a copy of my application form details by email  No Yes