Agent Number:
 

Agent Number

 

FAIS:
 

FAIS Licence No

FAIS Licence Type

 

Business Detail:
 
Name of Business
Company Type
Company Registration No

 

Individual Business Detail:

 
Title
Initials
First Name/s
Surname
ID Number
Date of Birth

 

Applicable Occupation Group:
 

Occupation Group

 

Confirm Address Detail:
 
Postal Address
 
Suburb
City
Code
Physical Address
 
Suburb
City
Code

 

Confirm Contact Detail:
 
Area Code
Telephone No
Area Code
Fax No

Cell No

Email Address

 

 

 

Banking Details:

If you prefer commission payments via Electronic Fund Transfer:

 

Account type  
Bank Account Number  
Bank Branch Code

Account Holders Name

 

 

Select Yes/No - Are you a Provisional Tax Payer

 

 

Tax Number:

 

 

VAT Vendors please provide VAT number:

 

 

IBC & SAFSIA Numbers:
 

IBC NO

SAFSIA NO

 

 

Are you a Credit or Direct Agent

 

If CREDIT - Provide IGF Detail:
 

IGF Number

IGF Expiry Date

Guarantee Amount

 

IGF Guarantee Name

 

 

Remarks & quote all agency codes if more than one: