Post on 19-Jul-2020
Network Leadership (PTY) Ltd
Longmeadow Business Estate East, 20 Devon Place, Modderfontein
PO Box 914, Edenvale, 1610
Tel: 0861 628 821
PAYMENT DETAILS
Snapscan Credit Card Authorisation
Master American Express
Visa Diners Club
Credit Card Number CVC Expiry Date
AUTHORISED SIGNATURE (ONCE OFF PURCHASE)
Signed at: …………………………………….……………………………………………………….. Date: / /
Signature: ..……………………………………………………………………………………………………………………………………………………………..
Account Holder: ………………………………………………………………………………………………………………………………………………………………
PERSONAL DETAILS
Upline Sponsor: …………………………………………………………… Platinum: ……………………………………………………………
Emerald: …………………………………………………………… Diamond: ……………………………………………………………
First Name: …………………………………………………………… Surname: ……………………………………………………………
Email: …………………………………………………………… ID Number: ……………………………………………………………
Contact Number: …………………………………………………………… Cell No: ……………………………………………………………
BUSINESS SUPPORT MATERIAL (Once off Purchase)
Item Code Item Description Unit Price QTY Total
CSPB031 Launch your Business R R
BBS Ticket R R
WES Ticket R R
Order Total R
BUSINESS SUPPORT MATERIAL—ONCE OFF ORDER
OFFICE USE ONLY
Date Captured ……………………………………………. Captured By …………………………………………….
Postnet Address Details …………………………………………………………………………………………………………………………
Direct Delivery …………………………………………………………………………………………………………………………
………………………………………………………………Postal Code ……..……………………………
Above delivery options charged at R70.00 per order weighing less than 2kg. For outlying areas direct delivery charged at R150.00. Prices subject to change without prior notice due to fuel levy fluctuations.
Office Collection JHB CTN DBN Botswana Namibia (No charge)
(Please provide a convenient work or home address for delivery in
working hours)
NETWORK LEADERSHIP (PTY) LTD—Registration Number 97/10736/07—VAT Number 4270167887
ABO NUMBER
CONTINUING EDUCATION PROGRAM—MONTHLY SUBSCRIPTION REGISTRATION FORM
PAYMENT DETAILS
Credit Card Authorisation
Master Visa American Express Diners
Credit Card Number CVC Expiry Date
Debit Order Authorisa on
Bank Name ………………………………………… Type of Account Current Savings Transmission
Branch Name ………………………………………… Branch Code ……………………………………………………………….
Payment Date: 1st 15th 25th of each month Account Number ……………………………………………………………….
1st Debit Only— Action debit on first available debit date
PROGRAM SELECTION
Basic (4 Audio CD’s) @ R245 Basic + Recommended Book @ R365
Professional (6 Audio CD’s) @ R365 Professional + Recommended Book @ R485
AUTHORISED SIGNATURE (MONTHLY SUBSCRIPTION)
Signed at: …………………………………….……………………………………………………….. Date: / /
Signature: ..……………………………………………………………………………………………………………………………………………………………..
Please Note: This is an ongoing subscription. By having signed the Subscription Form, you indicated acceptance of the following Terms and Conditions:
1. Network 21 (PTY) Ltd will charge your selected payment option for the indicated amount on the selected payment date every month in advance, while your subscription remains in force.
2. Modifications of your subscription must be received at least 30 days before delivery is made.
3. Your subscription will remain in force until cancelled by you in writing. In this instance, no refunds are applicable.
4. Prices subject to change without prior notice.
Account Holder: ………………………………………………………………………………………………………………………………………………………………
OFFICE USE ONLY
Date Captured ……………………………………………. Captured By …………………………………………….
NETWORK LEADERSHIP (PTY) LTD—Registration Number 97/10736/07—VAT Number 4270167887
ABO NUMBER PERSONAL DETAILS
Upline Sponsor: …………………………………………………………… Platinum: ……………………………………………………………
Emerald: …………………………………………………………… Diamond: ……………………………………………………………
First Name: …………………………………………………………… Surname: ……………………………………………………………
Email: …………………………………………………………… ID Number: ……………………………………………………………
Contact Number: …………………………………………………………… Cell No: ……………………………………………………………
Postnet Address Details …………………………………………………………………………………………………………………………
Direct Delivery …………………………………………………………………………………………………………………………
………………………………………………………………Postal Code ……..……………………………
Above delivery options charged at R70.00 per order weighing less than 2kg. For outlying areas direct delivery charged at R150.00. Prices subject to change without prior notice due to fuel levy fluctuations.
Office Collection JHB CTN DBN Botswana Namibia (No charge)
(Please provide a convenient work or home address for delivery in
working hours)
ABO NUMBER