Entry date: | Wednesday 6th November, 2024 |
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Title: | |
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Initials: | |
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First names (personal name): | * |
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Surname (family name): | * |
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Postal address, line 1: | * |
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Postal address, line 2: | |
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Postal address, suburb: | |
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Postal address, city: | * |
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Postal address, province: | |
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Postal address, code: | |
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Postal address, country: | |
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Company name: | |
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Physical address, line 1: | |
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Physical address, line 2: | |
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Physical address, suburb: | |
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Physical address, city: | |
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Physical address, country: | |
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Mobile phone: | * please enter at least one contact phone (mobile or work or home) or email in the labelled fields |
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Work phone: | |
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Home phone: | |
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Fax: | |
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Email: | @ |
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ID number: | |
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ID type and country: | |
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Occupation: | |
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Birthday: | |
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Wedding anniversary: | |
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Mode of payment: | Direct banking: Deposit CRESTA LODGE GABORONE, Stanbic Bank, Fairgrounds Branch, A/C # 9060000434855, Branch code 064967. Please email the deposit slip to: office@creativehouse.co.bw or fax to 390 0635, ensuring your name is on the slip |
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Payment arrangements: | |
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Date for effecting payment arrangements: | |
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Payment arrangements/ Collection advice/ Other notes to Cresta Pride Connect Club: | |
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Existing Cresta card number is: | |
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I was referred to Cresta Pride Connect Club by: | |
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Lead (office use only): | |
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