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Isiqqebamor er:' : :rt ii,vahoo.com

Contact:Scclo Ngcobo
Contact Number' 083 886 9010

MEMBERSHIP REG ISTRATION FORM

1. fers*nal lnformation
TITLE: Etvtr Etvtrs Ms E Other, specify:
Full Names: Nloh^-BtKa.Vrgf PX,gK* CaCA e A

Address: B z+C,\yz+r{/s z/+N6 Ro*o

AtQw €LEZftNg
Town/City: e nF* NA€N 1

Number of
Post Code: .3"-80 Contracts with
Di
Coin it Trading
(Pty) Ltd
Province :

Details of the
Lzlv
Member:
ldentity Number Qoc:3rB0"TZTOBZ
Cellphone Number o1a o3t Lg 37
Work/Alternate Phone
Number c1l 2G+ tb 3l
Email ntr" bi k aU i *e1t..tL..t q@, 3wrdl, c cru-r

Secondary Email
Sne ge-aLo@ J r-o)l,c:ot'.

Contract(s)
Number: C 2o11 'z5LA

Name & Surname e ,t ntlu' ct Ct cal-q

Details of Relationship dh ," o l,te,
Beneficiary
ldentity Number nt CI7 2z o+ 1z o8B
Cellphone Number: o -1 t z+ z7 31 CI
 ?. Paynnent informalion
I paid my membership fee ofglgjr via Bank Transfer/ Cash Deposit. Account
details:Mr N.E Sibiya Capitec ,Acc.No.1762060114 Cell No.0784942536 Please
use your Surname ahd Name" as reference and send bank transfer/deposit proof to
Isigqeba movement' s email.

o Acknowledgement Receipts will be issued on request'

o The [/embership Form should be accompanied by the proof of payment slip.
o Our bank account details are available only on request
. lr'lembership will be effective once verification done and the payment
received by the movement
o No waiting period will be allowed

3. Seclaration
, /-'
N 7ou8i kAttr 5€ t S kA r4C/\54 agrees and confirms that I

do not belong to the Liquidation of Coinit in any way and have not signed any
documentation (claim forms/ power of attorney ) with the Liquidators. ljoin
the lsigqeba lVlovement voluntarily and I fully and wilfully understand that I
will
lVe *r&€N I
Ful
Witness Signature *, il . jr.ceL.*- Date a;2. oa. Zc'z 3

Or

rees and confirms that I

completed and signed all the Liquidators of Coinit i my own attorney's
documents with an aim of getting my investment which I later realised that it
will not yield the results as expected. I join the lsigqeba lVovement voluntarily
and no longer want Coinit to be liquidated. I am consciously aware that I will
observe and abide to all the rules and policies of the movement.
ltrlember Signature Signed at
Full Name & Surname
Witness Signature Date
Full Name & Surname
t- Ro nrr: hl4-CI ,-ubi k*al is e (i* *&q i -4" 6*rBrf CI*1 11 otrZ
{,-l\ n'o: 01 q oZ(
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01/09/2A?: 13:36

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Note Denos.i ,-
R200 00',
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Account Numbe. .
i{ererence , .3},}#
iuut, Dep #CE
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