REGISTERED BUSINESS NAME:

TRADING NAME:

TYPE OF COMPANY: PTYCLOSE CORPORATIONSOLE PROPRIETORPARTNERSHIPTRUSTOTHER

If other please spesify

REGISTRATION NO OR ID:

DATE OF REGISTRATION:

VAT NO:

FINANCIAL YEAR-END:

EMAIL:

BILLING EMAIL:

PHYSICAL ADDRESS:

POSTAL ADDRESS:

POSTAL CODE:

TEL:

FAX:

WEBSITE:

CONTACT PERSON:

CONTACT EMAIL:

CONTACT TEL:

CONTACT MOBILE:

OWNERS FULL NAME:

OWNERS ID NUMBER:

DESCRIPTION OF TYPE OF BUSINESS: RETAILHOSPITALITYSERVICEOTHER

If other please specify

TRADING HOURS:

WEEKDAYS

FROM:

TO:

SATURDAY

FROM:

TO:

SUNDAY

FROM:

TO:

HOW MANY TILL POINTS:

CURRENT POS PROVIDER:---ALIEN POSAXIOMIQRETAIL(SEMI-INTEGRATED)OMNI ACCOUNTSPILOT POSPOSITIVE POSPOWERTILLSEMI-INTEGRATED VERSIONTOUCH POINTUNIPOSVECTOR POSVECTRON POSWILLPOWERPOSOTHER

If other please specify

I PREFER TO RECEIVE A QUOTE / ACQUIRE THROUGH:NEDBANKSTANDARD BANK

CARD TYPES YOU WOULD LIKE TO PROCESS: AMERICAN EXPRESSDINERS CLUBRCS

GIVEN BY: (NAME OF ACCOUNT HOLDER)

ACCOUNT NUMBER:

BANK :

BRANCH:

BRANCH CODE:

TYPE OF ACCOUNT: CURRENT(CHEQUE)SAVINGSTRANSMISSIONOTHER

If other please specify