Rectron (PTY) Limited

No. 152 15th Road, Randjespark, Midrand, 1685, South Africa

P.O Box 76494, Wendywood, 2144, South Africa
Reg. No 1995/003772/07

Telephone: +27 11 203 1000 | Facsimile: +27 11 203 1940

Account number (for office use only)

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Company name Click here to enter text.

Branch you want to deal with Choose an item.

Email address Click here to enter text.

Registered name of dealer Click here to enter text.

Registered name of dealer Click here to enter Trading Click here to enter text.
text. name of
dealer
Previous trading/registered name Click here to enter text.
of dealer
Incorporated form of business Choose an item. VAT number Click here to enter text.

Are you part of a holding ☐ Yes ☐No

company?
Registered name of holding Click here to enter Registration Click here to enter text.
company text. number
Registered names of subsidiary Click here to enter text.
companies
SABC realer TV license number Click here to enter text.
(Please provide copy of TV license document in this pack)

Physical address Click here to enter text.

“Domicilium”  
Billing address Click here to enter text.

Postal address Click here to enter text.

Business telephone no (000) 000-0000  Business fax (000) 000-0000 

no 
Main contact person name First name: Surname:
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Email address Click here to enter text.
 
Company bank account details          

Bank Choose an item.

1
 Rectron (PTY) Limited

No. 152 15th Road, Randjespark, Midrand, 1685, South Africa

P.O Box 76494, Wendywood, 2144, South Africa
Reg. No 1995/003772/07

Telephone: +27 11 203 1000 | Facsimile: +27 11 203 1940

Branch name Click here to enter text. Branch code Click here to enter text.
 

Account number Click here to enter text. 

 
Type of account ☐ Savings ☐Cheque account
 
Account name Click here to enter text.

Details of Owners/Directors/Members and Partners

 
First name: Surname: Shareholding /Interest
Click here to enter text. Click here to enter text. 0%
ID Number: Residential address: Code:
Click here to enter text. Click here to enter text. Click here to enter text.

First name: Surname: Shareholding/Interest

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ID Number: Residential address: Code:
Click here to enter text. Click here to enter text. Click here to enter text. 

First name: Surname: Shareholding/Interest

Click here to enter text.  Click here to enter text. 0%
ID Number: Residential address: Code:
Click here to enter text. Click here to enter text. Click here to enter text. 

First name: Surname: Shareholding/Interest

Click here to enter text. Click here to enter text. 0%
ID Number: Residential address: Code:
Click here to enter text. Click here to enter text. Click here to enter text.

Trade references

 
Name Telephone number
Click here to enter text. (000) 000-0000 

Credit limit in Rands Residential address: Code:

R Click here to enter text. Click here to enter text.

Name Telephone number

Click here to enter text. (000) 000-0000 
Credit limit in Rands Residential address: Code:

2
 Rectron (PTY) Limited

No. 152 15th Road, Randjespark, Midrand, 1685, South Africa

P.O Box 76494, Wendywood, 2144, South Africa
Reg. No 1995/003772/07

Telephone: +27 11 203 1000 | Facsimile: +27 11 203 1940

R Click here to enter text. Click here to enter text.

Credit limit in Rands Residential address: Code:

R Click here to enter text. Click here to enter text.

Name Telephone number

Click here to enter text. (000) 000-0000 
Credit limit in Rands Residential address: Code:
R Click here to enter text. Click here to enter text.

Credit requirements  
(We offer 7 & 14 days from weekly statement /30 days from month end statement depending on CGIC approval & your payment
history)

Terms needed Choose an item.

   
Legal compliance
 
List all sureties where applicable Click here to enter text.

Do you want to be added to our In which way do you prefer Choose an item.
mailing list? receiving information?
☐ Yes ☐No

Signatory
 
First name of Click here to enter Position of Click here to enter text.
authorised text. authorised  
signatory signatory  
Physical address (Domicilium) Code Click here to enter text.
Click here to enter text.

Telephone (000) 000-0000   Cell phone (000) 000-0000   

number number  
email address Click here to enter text.

 
*This field is compulsory
By my signature below, both as representative of the dealer and as surety and co-principal debtor with the
Dealer in terms of the Deed of suretyship contained in section C hereto, I hereby warrant that I have read,
understood and accepted that the said terms and conditions are binding on me as the Dealer and as the
surety. I confirm that my attention has been drawn to the deed of suretyship, the Warranty Policy, the Repairs
and Replacement Policy and that I have had the opportunity to consider same prior to signing the Dealer
application, the standard terms, conditions of sale and the Deed of Suretyship.

3
 Rectron (PTY) Limited

No. 152 15th Road, Randjespark, Midrand, 1685, South Africa

P.O Box 76494, Wendywood, 2144, South Africa
Reg. No 1995/003772/07

Telephone: +27 11 203 1000 | Facsimile: +27 11 203 1940

Signature

(Should the authorised signatory not be listed as a Director, the signatory must supply a letter of Authority )

Authorisation Authorised signatory: ☐ Yes ☐No

or
Letter of Authority supplied: ☐ Yes ☐No

Date dd/mm/yyyy
  
For office use only
 
Credit R    Terms Click here to enter text.
approved/COD approved and  
detail  
Approved by: Click here to enter text.
 
Signature  
 
 
 
 
Send completed forms through to salesadmin@rectron.co.za