Please note that this registration form is for the Contracted/Credit Account Customers only.

Kindly fill in all required information below and submit the form. Once we have received the completed form, the logins will be sent to the email provided, which will enable you to sign in as account holder/existing customer.

CUSTOMER INFORMATION
Name of the Customer/Department:
Name of the Division:
Cost Center Number (If Applicable):
Branch Physical Address:
Primary Accounts Liaison Officer:
Full Name:
Phone Number:
E-mail:
Secondary Accounts Liaison Officer:
Full Name:
Phone Number:
E-mail:
Invoicing Cycle
Invoice Distribution Preference
POD Distribution Preference:
SPECIAL REQUIREMENTS:
DETAILS OF SIGNATORY
Name:
Surname:
Designation:
Date:
Signature:

All services subject to the Standard Terms and Conditions of Madibana SA (Pty) Ltd as amended from time to time. Directors: Mr Madiba Madibana (Managing Director), Mrs Mmakgabo Mohloana (Financial Director)