Date Monday October 02, 2006
Name
Surname
Email
Address:
Postal code :
Tel No
Cell no
Where did you see our advertisement/ heard about us ?
Where is your nearest Post Office for Delivery ?
How much do you smoke per day ? How long have you been smoking ?
STANDARD BANK POTCHEFSTROOM Branch Code :053 838 PLEASE FAX THE SLIP TO (018) 290 5336 OR EMAIL A SCANNED COPY TO stopsmoke@mail.com
Account Name: K Venter
Referral : Your Name
Account No . 134 948 475 (Savings account)
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