APPLICATION FOR CREDIT

PERSONAL INFORMATION:

Title

 Ms Mrs Miss Mr Prof Dr

Surname

Home Address

For how long

Postal Address

Email Address

First Name

Code

Home Tel No

Cell No

If residential address has changed within a year, please give:

Previous Address

WORK INFORMATION:

Employer

Business Address

Business Tel No

Occupation

Code

For How Long

MEDICAL AID INFORMATION:

Spouse or relative's full names, address & contact number(if student, state parent's contact details):

Medical Aid

Name of Main Member

Dependant's Names

Medical Aid No

How long a member

OTHER TRADE REFERENCE INFORMATION

Trade Reference

Trade Reference

Trade Reference

Account No

Account No

Account No

FRIENDS/FAMILY INFORMATION

Name & address of family/friends staying at a different address

Title

 Ms Mrs Miss Mr Prof Dr

Surname

Home Address

Email

Cell No

First Name

Code

Home Tel No

CREDIT AMOUNT REQUIRED:

Credit Required

I certify that the above information is correct.

IF ANY MEDICAL AID DOES NOT PAY ANY CLAIMS OF DIE BOORD/MEDI-HEALTH/STELLENBOSCH SQUARE/EIKESTAD MALL PHARMACY ON MY BEHALF, I CONSENT THAT THE FULL AMOUNT OF REJECTIONS BE CHARGED TO MY ACCOUNT.

If I do not pay the current balance on my account within 30 days, I consent that interest be added at 22,25% per year.

I undertake, if I do not pay the current balance on my account within 30 days and it is handed over to attorneys for collections, to pay all legal costs to attorney and client scale, including collection commission at 10%, as well as tracing costs, if applicable.

If any of the above-mentioned information changes, I undertake to inform the pharmacy within 14 days in writing by registered post or by hand of such change.

I consent to the jurisdiction of the Magistrate’s Court, notwithstanding the amount of the claim. For the purpose hereof, I choose domicilium citandi et executandi at the above-mentioned address.

Date

I.D. Number

Upload ID

Upload Proof of Address