Declaration

National Credit Regulator
Form 39 Statistical Return
1	Name of Registered Entity
2	NCR Registration Number						DTI CIPRO No
3	Start of reporting period					dd/mm/yyyy
4	End of reporting period					dd/mm/yyyy
5	Number of branches registered with NCR
6	Name/ designation person completed this form
7	E-Mail
8	Contact telephone number				Code		Number
DECLARATION
I am duly authorised to sign this statistical  return.
I declare that this return is a fair and accurate representation of credit agreements entered into by the registered entity during the reporting period.
Name:
Signature:
Date:    dd/mm/yyyy