Independent Service Provider Account Application Form

Is this a request for the creation of an Independent Service Provider that does not yet exist on the database?

Category:

Independent Service Provider

Individual:

Title
First Name
Last Name
ID Number

Organisation:

Legal Entity Name
Trading as
Company Reg. No.
VAT Reg. No.
Natis No.
RMI Reg. No.
Enterprise No.

Contact Person:

Title
First Name
Last Name
Email Address
Tel No.
Fax No.
Cell No.

Physical Address:

Street/House No.
City
City Postal Code
Country

Banking Details:

Bank Name
Bank Branch Code
Account Number
Account Holder
Collection Authorisation

Postal Address:

P.O. Box
City
Postal Code

Originator Details: [For Office Use Only]

First Name
Last Name
Department
Tel No.
Effective Date
Date Requested

Disclaimer:

  1. I warrant that the information provided herein is to the best of my knowledge true, correct and complete.
  2. I acknowledge that the submission of this form, will not automatically give me access to training and technical information of DTSA and that the application is subject to approval by DTSA.
  3. I agree and understand that any approved application will be subject to the specific terms and conditions of the product/part/information I am intending to purchase/subscribe to.
  4. I hereby consent to a credit check being conducted and consent to any further checks which may be required as determined by DTSA.
  5. I hereby specifically consent to the sharing of my personal information to any DTSA Affiliate and/or Agent where required to fulfill the services.
  6. I further specifically consent to the use of my / the company's Personal Information as provided herein for the purposes of this Agreement in line with POPIA, as well as for the purposes of marketing and Direct Marketing to me by DTSA or its affiliates.