Centracom Dealer Application
Company Information
Legal Company Name
*
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Trading As
Registration Number
*
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VAT Number
Billing/Postal Address
*
Street Name / Box Number Suburb City Postal Code
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Physical Address
*
Street Name Suburb City Postal Code
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Contact Information
Primary Contact
*
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Telephone
*
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Fax Number
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Primary Contact Email Address
*
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Primary Contact Mobile Number
*
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Notifications Email Address
*
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Banking Information
Bank
*
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Branch Name
*
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Branch Code
*
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Account Number
*
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Account Name
*
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Duplicate Company Name
The Company Name you have provided already exists as a Customer or Dealer on the Centracom database
Please contact
support@centracom.co.za
for advice on how to proceed