Registered Customer

CUSTOMER INFORMATION

CUSTOMER DETAILS

Type of business: (x) Sole Proprietor Pty (Ltd) Partnership Ltd Trust Full registered name: Trade name: Registration number: V.A.T. number: Nature of business: Physical address: Postal address: Telephone number/s: E-mail address: Fax number: Cell: Person(s) authorised to order: Department: Contact name in accounts dept: Completed by:

Name: Designation: Date: Signature: Port Elizabeth Tel: + 27 (0-41-486-****

Port Elizabeth Fax: + 27 (0-41-486-****

Rosslyn Tel: + 27 (0-12-541-****

Rosslyn Fax: + 27 (0-12-541-****

Cell: + 27 (0-82-571-****

Email: ****@******.**.**

Website: www.pechem.co.za

137 Grahamstown Rd

Deal Party

Port Elizabeth,

6001

(Reg. Nr. CK 1994/09960/23)

60 Moore Street

Wadeville,

Germiston

Tel: 011-***-****/4776

Fax: 011-***-****

PO Box 7056

Newton Park

Port Elizabeth

6055

PO Box 911-872

Rosslyn,

South Africa,

0200

PE

Chemicals cc Vat: 483*******

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