CUSTOMER PROCUREMENT FORM

Category of Procurement *

Customer Type *

Payment Currency *

Payment Method *

Purchase Order Name *

Phone Number *

Personal Information

Title*

Surname*

First Name *

Other Names

Address *

Nearest Landmark *

Type of Order

Email Address*

Social Media

Social Media Handle*

MAILING ADDRESS

Recipient’s Name*

Business Name (if applicable)

Address *

State

Zip Code:

Phone Number:

Disclaimer

All clients whose goods are to be delivered to them and do not have to or want to pick up from our office or live in an area where we do not have an office are required to have a means of identification.

By clicking “SUBMIT” it is agreed that the information/document supplied here are given herein, are on the basis of procurement of goods and therefore warrant this information is correct. That the terms and conditions governing the operation of this transaction which are presented overleaf and agree to be bound by them.