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Company’s Legal Name

Company’s Operating Name

Street Address

Country

City

Province/State

Postal Code

Website

Is this your corporate head office?

Yes

No

First Name

Surname

Business Title

Email Address

Telephone Number International number format required e.g. +27 21 761 0000

Cellphone Number International number format required e.g. +27 82 812 1234

Give a short description of the product(s) and/or service(s) you provide.

Are you registered with MasterCard/Visa?

Yes

No

Which of the following apply to your company? Choose all that apply.

EME (turnover <R10 million)

QSE (turnover >R10 million; <50 million)

Generic (turnover >R50 million)

BBBEE certified:

Level

Non-compliant

Level

> 51% black ownership

> 51% black female ownership

Financial Year End

Latest audited financial statements results

Yes, I have read and agree with Capitec's Supplier Code of Conduct

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Supplier registration