Individual Take-on Form

Individual Client Take-On Form

Dear Client,

Thank you for joining the Eco Maniacs Client Base.
Kindly note that your information will not be shared with any 3rd parties, nor will you receive any marketing emails from us unless you have subscribed.

We are a proud supporter of the POPI Act (Protection of Personal Information) – Please refer to our Privacy Policy

Regards
PC Maniacs

APPLICANT NAME IN FULL:

APPLICANT ID NUMBER:

APPLICANT EMAIL ADDRESS

POSTAL ADDRESS:

STREET ADDRESS:

INVOICES TO BE SENT TO:

TELEPHONE NUMBER/S:

FAX NUMBER/S:

NEXT OF KIN NAME: (Person not living with you)

NEXT OF KIN ID NUMBER

NEXT OF KIN RELATIONSHIP

NEXT OF KIN CONTACT NUMBER

SIGNED AT:

DATE:

YOUR DESIGNATION

I hereby confirm that the above is true

Individual Take-on Form

Covid-19 Information

Quick Links

Policies

JOHANNESBURG Branch

Pretoria Branch