CUSTOMER DETAILS:

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”*