CLIENT INFORMATION FORM

Completion Date:

1. Client / Subscriber Details

Client Type *

Company / Juristic Person Individual / Natural Person

Full Legal Name / Company Name *

Trading As (if applicable)

Registration / CIPC Number or ID Number *

VAT Number (if registered)

2. Address

Address Line 1 *

Address Line 2

Suburb *

City *

Province *

Postal Code *

Postal Address is the same as Physical Address

Postal Address Line 1

Postal Code

3. Primary Contact Information

Contact Person / Authorised Signatory *

Position / Title

Email Address (will also be used as login username) *

Telephone Number *

Mobile Number

4. Billing Information

Billing Contact Name (if different from primary contact)

Billing Email Address

Billing Telephone Number

Important: All invoices are processed and emailed to the designated billing contact.

5. Account Login Credentials (for sign-in & future agreements)

Create your secure login details. Your email above will serve as the username.

Password *

Confirm Password *

7. Human Verification

Verify you are human * Click to reveal question What is 5 + 3 ?

8. Agreement Acceptance

I have read, understood and agree to the Terms of Service I have read, understood and agree to the Acceptable Use Policy I have read, understood and agree to the Privacy Policy

By submitting this form you authorise Bchange Online to create your client account and enter into new service agreements using the information provided.

9. Declaration & Digital Signature

I confirm that all information supplied is true and correct. I understand that this completed form, together with the attached Terms of Service, Acceptable Use Policy and Privacy Policy, constitutes my agreement to become a Subscriber.

Authorised Signatory Full Name (Digital Signature)

Date of Signature: