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Checkers Business Card Application


1. Applicant Details    

Registered Name of Business:
Trading Name:
Physical Address:
 
  Postal Code:
Business Registration Number:
Postal Address:
 
  Postal Code:
Applicant Contact Details
Telephone Number:
Cell Phone Number:
Fax Number:
E-mail Address:

2. Details of Authorised Representative    

Title:
Names:
Identity Number:
Designation:
Initials:
Surname:
Date of Birth:
Select a date from the calendar.
Authorisation:
I hereby confirm that the information provided is true and correct and that I have the authority to do so.
We require a scanned copy of the representative's green barcoded ID book:
We require a scanned copy of a utility bill as proof of residence:

3. Bank Account Details    

We need this information to assess your credit status:
Name of Bank:
Account Holder's Name:
Type of Account:


Account Number:
Branch Code:
How many years have you banked there?:

4. Debit Order Authorisation    

Would you like to pay your Checkers Business Card by debit order:
If yes, please complete the details below:
Name of Bank:
Bank Account Name:
Type of Account:


Bank Account Number:
Branch Name:
Branch Code:
 
Authorisation:
I hereby confirm that the information provided is true and correct and that I have the authority to do so.
 
We require a scanned proof of banking details in the form of a cancelled cheque or certified copy of your current bank statement.

5. Preferences    

Would you like to receive your communication in:
If for some reason it is not possible to communicate with you in your preferred language, we will communicate with you in English
Would you like to receive your statement via:
Would you like to receive important account information via SMS:

6. Purchase Limit    

Purchase limit applied for:
R

7. Signature    

I hereby confirm that all details supplied above are true and correct. I acknowledge that I have read and understand the Terms and Conditions attached to this application form and undertake on behalf of the Applicant to abide by the rules governing the Checkers Business Card. I warrant that I am duly authorised to make this application on behalf of the Applicant.

Type your full name as a signature:
Designation:
Date:
Select a date from the calendar.
Submit