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Fields marked with an * are required
YOUR NAME or ORGANISATION NAME (required)
YOUR CONTACT NO.*
YOUR EMAIL ( Use Correct Email )*
CITY & COUNTRY:
WHO DID YOU REFER TO BUY PRODUCTS?:(Mention Name & Contact No.”)
WHICH PRODUCTS DID YOU BUY?:(Mention Them & How Many?)
HOW MUCH DID YOU PAY & HOW DID YOU PAY?:(State amount & method of payment)
ORDER & REFERRAL INFORMATION:
SELECT PAYMENT RANGE DONE BY YOURSELF or REFERRAL:—@-Low Range : R50 to R450.@-Medium Range : R451 to R1500.@-High Range : R1501 to R4000.
WHEN DID YOU or YOUR REFERRAL BUY PRODUCTS?:(Mention Date)
WHICH PRODUCT CLASS DID YOU or YOUR REFERRAL PURCHASE?:—1- PADS2- SNEAKERS3- CLEANING4- SPRAYS5- FOOD STUFF6- COSMETICS7- GADGETS8- STEM CELLS9- ELECTRONICS10- OTHER
YOUR BANK DETAILS : “Put Title – “MY BANK DETAILS”*
E.G:”Below Please Write Your Bank Name, Account Number, Account Type & Branch Code!”
ATTACH PROOF OF PAYMENT DONE BY YOU or YOUR REFERRAL : (File types: pdf,img,jpg,jpeg,tif,png | Max. file size 10MB)