DH Brothers Industries (Pty) Ltd

Co. Reg. Number: 1964/006746/07 VAT Reg. Number: 4170117792

266 Ohrtmann PO Box 384 Tel: (033) 3557800

Road Pietermaritzburg Fax: (033) 355 7868
Willowton 3200 Email:
Pietermaritzburg sales@wocm.com

Application Form for COD Customers

Customer Details
Customer Name:
(As Registered)
Company Reg. No:
Trading Name:
Registered Address
Business Type  Close Corporation  Pty (Ltd)  Ltd
(tick )  Trust  Partnership  Sole Proprietor
VAT Registration No.

Postal Address
Code:

Physical Address
Code:

Delivery Address
Code:
 Tel 1  Fax 1
Contact Details
 Cell  Email
Directors/ Partners/ Members/ Trustees
Contact
 Name
No:
Physical Address
ID
 Email
Number:
Contact
 Name
No:
Physical Address
ID
 Email
Number:
Trade References
Name of Company  Tel No:
 Email  Fax No:
Address
Name of Company  Tel No:
 Email  Fax No:
Address
Name of Company  Tel No:
 Email  Fax No:
Address
DH Brothers Industries (Pty) Ltd Banking Details
Name of Bank STANDARD BANK Branch: 0 5 7 5 2 5
Account Number 0 5 2 2 1 1 4 4 4
Address LONGMARKET STREET, PIETERMARITZBURG Code: 3201

Goods remain the property of DH Brothers Industries (Pty) Ltd until paid for in full.

I ___________________________________ (print name and surname) agree with the above set conditions and confirm
that the above details provided are true and correct.
 DH Brothers Industries (Pty) Ltd
Co. Reg. Number: 1964/006746/07 VAT Reg. Number: 4170117792

266 Ohrtmann PO Box 384 Tel: (033) 3557800

Road Pietermaritzburg Fax: (033) 355 7868
Willowton 3200 Email:
Pietermaritzburg sales@wocm.com

Signature:_________________________________ Designation:_________________________________ Date:_____/______/______