OPEN A LOYALTY CARD

PERSONAL INFORMATION

Title

 Ms Mrs Miss Mr Prof Dr

Surname

ID Number

First Name

Date of Birth

Marital Status

 Single Married Other

Sex

 Male Female

YOUR CONTACT DETAILS

Work No.

Cell No.

Tel No.

Email Address

Number of Children

Language

Postal Address

Code

Physical Address

Code

Occupation

 Employed Student Home Executive Pensioner

Interests which you would like information on:

 Vitamins & Minerals Herbal & Homeopathic Nutraceuticals Sport Nutrition Slimming Tonics & Probiotics

 Woman's Health Children's Health Beauty & Skin Care Diabetes AIDS / HIV

Other

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

Do you exercise more than once a week?

As a Loyalty Program holder, we would like to update you on new product launches, product information, promotions and special events of interest to you - as well as updating you on your point status.

Please let us know the best way to do this:

 SMS EMAIL POST