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iro.co.za

A MEMBER OF THE GROUP

Gauteng 9 Landmarks Avenue Kosmosdal Samrand 0157

Tel: +27 12 657 0960

Cape Town Unit 14 Frezzitta Business Park Cnr Koeberg Road & Freedom Way Milnderton Cape Town 7441

Tel: +27 21 555 3207

Durban Unit 3 Thynk Retail Park 23 Riverhorse Road Riverhorse Vally 4017

Tel: +27 31 564 7283

Nelspruit Unit C2 Waterfall Park 55 Rapid Street Riverside Industrial Nelspruit 1200

Tel: +27 13 752 4654

PO Box 4487 The Reeds 0158

086 123 MIRO(6476)

www.miro.co.za

Hudaco Trading Pty Ltd Reg No. 1984/005432/07Directors: G.R. Dunford (Managing), C.V Amoils, D. Naidoo*, N. Mandindi*

(*Independent Non-Executive) Secretary: Hudaco Group Financial Services Pty Ltd

BUSINESS PARTNER REGISTRATION FORMPlease complete this form and Email it back to us at: sales@miro.co.za

Alternatively, consider filling out our online application form for your convenience.http://www.miro.co.za/become-a-business-partner/

Registered Name of Business:

Trade Name of Business (if different):

Office Tel. Number: (or cellular): Physical Address:

Company Website URL:

Type of Business (Form of incorporation): Sole Proprietor Partnership Trust CC (Pty) Ltd Ltd

Company Registration Number: VAT Registration Number:

Nature of Business: End User Installer Reseller Internet or Voice Service Provider Other :

PLEASE SUPPLY THE FOLLOWING CONTACT DETAILS

Email address for Quotes & Invoices:

Cell number for SMS payment confirmations:

Primary contact person name: Primary Mobile Number: Primary Email Address:

Accounts Name: Accounts Mobile No: Accounts Email:

Buyer Name: Buyer Mobile No: Buyer Email:

Additional Contacts to receive Product & Marketing Information: Name & Email

Which other trade suppliers are you registered with?

Where did you hear about us? Google MiRO External Sales Internet/Website Magazine Referral Trade Show

Please specify the publication/website/referral/show or other:

I (Full names)____________________________ ID Number ____________________in my capacity as (position)_____________________ of (business names)_____________________________hereby confirm that:

1. The information contained in this document is true and correct,2. I am duly authorised to enter into agreements for/on behalf of the applicant,3. I have read and understood the Miro terms & conditions of trade and accept them as binding upon the applicant,4. I understand that this is a business partner registration only and not a credit application.

Signature __________________________________ Date______________________