Applicant Email Address Applicant Mobile Number


Applicant Name Applicant Surname


Applicant Designation Business Name

Other Business Type
Street Address Postal Address
Telephone Number Facsimile Number
Business Registration Number Vat Registration Number
Business Email Website
What is the nature of business activities carried out by applicant
Directors/Members/Partners Details
Name(Required) Surname(Required) ID Number
Contact No

Sales/IT/ Technical Managers Details
Name (Required) Surname (Required) Email Addresses
Account Managers Details
Name (Required) Surname(Required) Email Address(Required) Contact No
Trade References
1. Reference Name Reference Tel No
2. Reference Name Reference Tel No
3. Reference Name Reference Tel No
How long has the Business been Trading under present management(years) If Applicant is a subsidiary State Name and Address of Holding Company

Please enter numeric values only
Maximum amount of anticipated credit Purchase per month: R  

Please enter only numbers like 100 or 10000
We also require the following documents which can be uploaded here or you can email them to
Please note that you can only upload pdf files.
Company Registration(Max Size 2MB)

Copy of Directors ID(Max Size 2MB)

Proof of Bank account (Not older than 3 months)(Max Size 2MB)