DISTRIBUTOR APPLICATION FORM

Please fill out the following form

INDIVIDUAL

COMPANY

Full Name

Reg No/ID NR:

Current Physical Address:

Website:

Tel No

Other:

Vat Reg Nr:

Name:

Surname:

ID Number:

Contact Number:

Position:

Employed

Transport

Company Name:

Occupation:

Do you have any experience in water treatment

State your interest in water (write answer)

Do you consent to us calling you on this number provided for a telephonic interview?

When will it be convenient Date

Time

The fee of R1 999.00 upon acceptance - to register.