Customer Sign Up Form

Customer Details

 

 

Date of birth:

 

ID/Passport No:

 

Phone:

 

Current address:

 

City:

 

Province:

 

Code:

 

Email address:

 

Postal address:

 

City:

 

Province:

 

Code:

 

Telephone number:

 

Fax number:

 

Mobile:

 

 

 

 

 

 

 

Account reference will be referred to as your telephone number.

 

 

 

 

 

 

 

 

 

 

 

 

Employment Information

Current employer:

 

Employer address::

 

How long?

 

Phone:

 

Email:

 

Fax:

 

City:

 

Province:

 

Code:

 

Position:

 

Hourly Paid:

 

           Salary:

 

Annual income:

 

Name of a relative not residing with you:

 

Address:

 

Phone:

 

City:

 

Province:

 

Code:

 

Relationship:

 

 

 

 

 

 

 

 

 

 

 

( FOR STUDENT ONLY )

Institute Name:

 

Faculty:

 

Student Id:

 

 

Phone:

 

Current address:

 

City:

 

Province:

 

 

Code:

 

 

 

 

 

 

 

PRODUCT INFORMATION

Meter taxi credit please Click in the circle next to the credit you are applying for :

 

 

 

 

 

 

 

 

 

 

 

R2000  Yearly R167 x 12  months

 

 

 

 

 

 

 

 

R6000  Yearly R500 x 12  months

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BILLING DELIVERY METHOD

 

 

 

 

 

 

 

 

 

 

EMAIL ADDRESS: