Restructuring application for individuals with overdue debts

The form contains the following set of fields:

«Surname» - Field type text (required)
«Name» - Field type text (required)
«Patronymic» - Field type text (required)
«IIN» - Field type text (required)
«Telephone number» - Field type text (required)
«Applicant’s e-mail» - Field type E-mail (required)
«The heart of thematter» - Field type dropdown list (required)
«Loan restructuring» - Field type dropdown list
«Term (in months)» - Field type dropdown list (required)
«Requested new monthly payment (in thousand KZT)» - Field type text
«Рефинансирование» - Field type multiple-choice drop-down list
«Reason» - Field type dropdown list (required)
«Duration» - Field type dropdown list (required)
«Describe the problem» - Field type multiple lines of text
«Confirming document» - Field type file
«I agree to pass additional identifications by telephone, in case of failure to pass identification, the application will be canceled» - Field type check box (required)
«I agree to the processing of my personal data, submitted by me» - Field type check box (required)

Surname *

Name *

Patronymic *

IIN *

Telephone number *

Applicant’s e-mail *

The heart of thematter *

Loan restructuring

Term (in months) *

Requested new monthly payment (in thousand KZT)

Рефинансирование

Reason *

Duration *

Describe the problem

Confirming document

I agree to pass additional identifications by telephone, in case of failure to pass identification, the application will be canceled *

I agree to the processing of my personal data, submitted by me *

Required fields marked *