Prepaid Account Application Form - Reitzer Healthcare (Pty) Ltd

Prepaid Account Application

Company Details:

Business Type(required)

CC (Pty) Ltd Sole Proprietor / Partnership Private Customer

Registered Company Name: (if registered on CIPC)

Company Trading Name: (if different to Registered Company Name)

Business Registration Number: (if registered on CIPC)

VAT Number: (if VAT Registered)

First Name & Last Name: (if none of the above is applicable)

Website Address or Facebook Page URL: (if available)

Physical Address / Business Address

Complex Name / Business Park Name

Unit Number

Street Number(required)

Street Name(required)

Suburb Name(required)

Province(required)

Postal Code(required)

Postal Address (If not the same as the above)

Address Line 1

Address Line 2

Province

Postal Code

Delivery Address (if different from Physical / Business Address)

Complex Name / Business Park Name

Unit Number

Street Number

Street Name

Suburb Name

Province

Postal Code

Contact Details

Name of Person Responsible for Account:(required)

Email Address:(required)

Business Email Address (if different from the above):

Business Telephone Number:

Mobile Number:

* Means Required

Terms & Conditions:

ONLY EFT payments are accepted.
Once your account application has been approved, you will receive an email with your account details, our Delivery Charges Document (Please see minimum order value for free delivery) and the Reitzer Healthcare Price List.
The minimum order value means the total value of the order after discount (if any) and excluding VAT.
Deliveries take place within 5 to 7 business days from receipt of payment and depend on stock availability.

Click on the link below to read our Terms & Conditions.

Direct Payment Terms & Conditions Download

By ticking this box I/we agree to the terms and conditions.(required)

By submitting this application, you agree that all the information and details filled in are true and correct. I/We undertake to notify Reitzer Healthcare in writing of any changes made to the information provided.