Investor Type IndividualTrustCompanyPartnership
Citizenship / Residency South AfricanUnited States of AmericaOther
Title
Forename(s) in Full / Entity Name *
Surname
Date of Birth (mm/dd/yyyy)
Tax Number
Identity / Registration No
Residential Address
Postal Address
Postcode
Email
Telephone (work)
Telephone (mobile)
Number of Ordinary Shares (R1000 per ordinary share)
Total Value
Source of Investor Funds:
Distributions, if any, that become due on the Ordinary Shares, will be paid directly into the Investor's bank account, as detailed below:
Bank
Branch
Branch Code
Account Name
Type of Account
Account Number
Δ
