BUSINESS REGISISTRATION FORM

Service Provider Registration Form

Important notes:

Please enter your business details exactly as you want them to show on the website - all fields are compulsory.
This is the basic information we need to confirm your application – you will be required to provide us with more comprehensive information later to enable us to accurately and comprehensively advertise your services.
For the sake of uniformity please use upper and lower case letters just like this form.
Confidential information like your bank details and the names and telephone numbers of your references will not be displayed on the site.
If you are paying via debit order please note that we need the first month’s payment upfront (debit order will only be activated from the second month) - please EFT or deposit into our account (Nedbank Business Free State, branch code 166234, account number 1662021917) and email proof of payment to or fax to 0865376238.
To ensure your bank details are captured correctly please also fax or email us a copy of a bank cheque or statement to the above.
Debit orders are only processed once a month, and ALWAYS on the 7th - we would really appreciate it if you could please ensure you have the necessary funds available on that date.

Membership Information

Membership Type

Premium

Premium Plus

Platinum

Platinum Plus

Payment Method

Monthly Debit Order from Bank

Monthly Debit from Credit Card

Anually in advance EFT from Bank

Anually in advance from Credit Card

Number of Branches *

* Please indicate if your business has more than 1 physical address from which you operate
(up to 5 different offices/branches maximum)*

* Up to 5 branches the cost of listing is multiplied by the number of branches and we will contact you for details of the other branches

* For groups with more than 5 branches/outlets please contact us for a discounted rate

Total Payment Amount

Please enter your details:

Company Name

VAT Registration Number (if exists)

Contact Name

Position in Company

E-mail Address

Street Address

Suburb

City/Town

Postal Code

Business Phone

Cell Phone

Normal Business Hours / 24Hrs?

Normal Business Hours

24Hrs

Website

(Enter the website link if you have a website)

Primary service/product
you provide

If the service is not listed above please indicate here:

Additional Services / Products
you provide

Main (Primary) Area
where you would you like your business to registered:

(this would be the area where your business is situated, and would be a town like Benoni or City Area like Pretoria East, not a suburb)

If the area is not listed above please indicate area here:

Additional (Secondary) Areas

(Nearby towns or cities that you are prepared to service)

Is your business BEE Registered?

If yes, please tick the box and after completing this form, fax a copy of your BEE certificate to 021-8560268 or email it to

BEE Registered

Authorised Person making payment
(Name and Surname)

Identity Number of Authorised Person

Comments