Membership Application

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Please note: Fields marked with an asterisk (*) are required.

Company Representative Name:	*
Name of Business:	*
Postal Address:	Postal Code:
Physical Address:	Physical Code:
Area:	*
City:
Telephone:	* (Please fill in if you haven't entered a cellphone number)
Fax:
Cell:	* (Please fill in if you haven't entered a telephone number)
Email:
Web Site:
Company/Close Corporation Registration Number:
VAT Registration Number:
PAYE Registration Number:
UIF Registration Number:
WCC Registration Number:
Public Liability Insurance Policy Number:
Name of Insurance Company:
Maximum Cover:
Pest Control Operator's names and Department of Agriculture Registration Numbers:	P:
	P:

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