BNPL Risk Assessment Form
Complete this form to assess BNPL eligibility, repayment readiness, and overall purchase risk.
Applicant Profile
Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Date of Birth / Age Range
*
Please Select
18–20
21–24
25–34
35–44
45–54
55+
Prefer not to say
Country/Region of Residence
*
Please Select
United States
Canada
United Kingdom
Australia
New Zealand
European Union
Other
Employment Status
*
Please Select
Employed full-time
Employed part-time
Self-employed
Student
Unemployed
Retired
Prefer not to say
BNPL Usage and Purchase Intent
Intended BNPL Purchase Amount Range
*
Please Select
Under $100
$100–$299
$300–$499
$500–$999
$1,000 or more
Prefer not to say
Intended Merchant Category or Purchase Type
*
Please Select
Electronics
Fashion/Apparel
Home Goods
Travel
Groceries
Health & Beauty
Furniture
Education
Other
Desired Repayment Term Length
*
2 weeks
1 month
2 months
3 months
6 months
Other
Have You Used BNPL Before?
*
Yes
No
Not sure
Reason for Using BNPL
Risk Assessment Inputs
Monthly income range
*
Under $1,000
$1,000-$1,999
$2,000-$3,499
$3,500-$4,999
$5,000 or more
Prefer not to say
Estimated monthly essential expenses range
*
Under $500
$500-$999
$1,000-$1,999
$2,000-$3,499
$3,500 or more
Prefer not to say
Existing debt burden level
*
Please Select
None
Low
Moderate
High
Very high
Prefer not to say
Repayment confidence
*
1
2
3
4
5
Self-assessment
*
Rows
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I keep a budget and track my spending
1
2
3
4
5
I usually pay bills on time
6
7
8
9
10
I tend to make impulse purchases
11
12
13
14
15
Review and Submission
Final review status
*
Ready to proceed
Needs review
Not sure
I confirm the information provided is accurate and complete
*
Option 1
Option 2
Option 3
Additional notes or explanation
Submit Assessment
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