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