Application form to get your business onto this Web site

Business Name:

____________________________________________________________

Contact person:

_____________________________________________________________

Postal address:

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

"Province"

____________________________________________________________

Telephone Numbers:

_____________________________ ______________________________

Fax numbers:

_____________________________ ______________________________

E-mail address:

____________________________________________________________

____________________________________________________________

Web site address:

http://_______________________________________________________

Category:

___________________________________________________________

Sub - category:

___________________________________________________________

Do you want to advertise your business in future by using your own Web site: YES / NO

Other questions / Comments:

____________________________________________________________

____________________________________________________________

____________________________________________________________

Description of Your Business:

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

Method of payment:

Cheque / Direct deposit

(Underline the appropriate option)

Post this form to: E-mail Info and Advertising CC, P.O. Box 3363, Paarl, 7620