Pre-Application Form

1
Are you new customer with MAXIMA?* This field is required.
Yes
No
2
Do you remember your MID?* This field is required.
YesNo
3
Input your MID* This field is required.
4
What is your name in Khmer?* This field is required.
5
What is your name in Latin? (Please input capital letter)
6
What is your gender?* This field is required.
Female
Male
7
What is your date of birth?* This field is required.
Day
Month
Year
8
What is your marital status?* This field is required.
Single
Married
Widow/Divorced
9
What's type of your career?* This field is required.
Employee
Business Owner
10
Career Type
11
What is your phone number?* This field is required.
12
Please select Maxima Branch that is near you* This field is required.Please be informed that we can only operate in the area listed below. We apologize for the inconvenience if your location is not on the list.
សាខាអរិយក្សត្រ
សាខាព្រែកអញ្ចាញ
សាខាព្រែកព្នៅ
សាខាកោះឧកញ៉ាតី
សាខាចោមចៅ
សាខាកងមាស
សាខាកៀនស្វាយ
សាខាថ្នល់ទទឹង
សាខាអូររាំងឪ
សាខាបន្ទាយមាស
សាខាពារាំង
សាខាកំពង់ឆ្នាំង
13
Maxima Branch that is near you
14
Please select your current address, we apologize if your province is not on the list because we are operating only these provinces* This field is required.
15
Your current address
16
Please click OK, then find your address location on the map, then drop the pin on it. Or you can input your location's latitude and longitude below if you know it.
17
Client's Address Location with Latitude and Longitude
18
Please select loan currency* This field is required.
KHR
USD
19
How much loan amount do you want to apply (KHR)?* This field is required.
20
How much loan amount do you want to apply (USD)?* This field is required.
21
Do you have a loan collateral?* This field is required.
Yes
No
22
What is your loan purpose?* This field is required.
Agriculture
Construction
Consumption
Education
Household Business
Service
Solar
Trade
Transportation
Other
23
When do you need this loan?* This field is required.
Day
Month
Year
24
How did you know about this loan?* This field is required.
Facebook Business Page
Good Neighbor Facebook Group
Pinih Pinus Facebook Group
Maxima Facebook General
Maxima Staff
25
Please upload your National ID Card/Family Book/Resident Book.* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 14.6MB
Cancelof
26
Unique MID
27
MID Generator* This field is required.
28
Your MID NumberPlease note this MID number for your future reference
Should be Empty: