Customer Information Form

Customer Information

Business Type

Public Co./Government

Private Co.

Close Corporation

Sole Proprietorship

Trading Name

Registered Name of Co/CC

Registration Number of Co/CC

Date of Registration

Type of Business

Physical Address of Registered Office

Postal Code

Customer Billing Information

VAT Registration Number

Postal Address

Postal Code

E-mail Address

Debit Order Billing Details

I/We hereby request and authorise E-mbizo to draw against my/our account held with the here within mentioned bank (or any other bank or branch to which I/we may transfer from my/our account) the Monthly sum of:

Non-Recurring: R

Amount in Words (Non-Recurring)

Monthly Recurring: R

Amount in Words (Monthly Recurring)

Commence Date

Banking Details

Bank

Branch

Branch Code

Account Number

Account Holder

Type of Account

Details of Director(s)/Member(s)/Partner(s)/Owner(s)

Name

Capacity

ID Number

Residential Address

Postal Code

Telephone Number

Mobile Phone Number

Subscription Plans

Select Plan

Price

Description