ABOUT: INFOCOUNTRY PRE-REGISTRATION	 	Date: ..../..../....

Can you please register my business to the InfoCountry service.

   Preferable JBNumber:	XXXXza.................... 

*  Business name: 	..........................

*  Province: 	Eastern Cape	[ ] 
		Freestate	[ ]
		Gauteng		[ ]
		Kwazulu Natal	[ ]
		Limpopo		[ ]
		Mpumalanga	[ ]
		North West	[ ]
		Northern Cape	[ ]
		Western Cape	[ ]

*  Town: 		.......................... 

   Town Extension: 	..........................

#* Phone number: 	.......................... 

#  SMS number: 		..........................

#  Email address: 	............................................

*  Maintenance type: 	An Editor must update the detail 	[ ]  
		   	We will update it by our selves		[ ]
			We will use both options		[ ]

  Street Address. 	...................................    

  Alternative message. 

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Notes: 	Preferable JBNumber cost R150 to set up. 
	The questions market with a * is required
	The questions market with a # will be used to contact you.
	Questions that are not applicable can be left empty.

I do understand that I have to pay the setup fee and 
make the necessary bank deductions to complete my registration.

I UNDERSTAND THAT I WILL BE BOUND TO THE TERMS AND CONDITIONS 
OF THE INFOCOUNTRY WEB SITE. 


.................
(Business owner)