CRESTA PRIDE CONNECT CLUB SERVICES form: membership application 2021/2022

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Please insert the relevant information, then select Submit. Use the TAB button and mouse to navigate. AVOID THE ENTER BUTTON while filling in the form. Red asterisks (*) indicate required fields
Entry date:

Sunday 25th July, 2021

Title:
Initials:
First names (personal name): *
Surname (family name): *
Postal address, line 1: *
Postal address, line 2:
Postal address, suburb:
Postal address, city: *
Postal address, province:
Postal address, code:
Postal address, country:
Company name:
Physical address, line 1:
Physical address, line 2:
Physical address, suburb:
Physical address, city:
Physical address, country:
Mobile phone: * please enter at least one contact phone (mobile or work or home) or email in the labelled fields
Work phone:
Home phone:
Fax:
Email: @
ID number:
ID type and country:
Occupation:
Birthday:
Wedding anniversary:
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: connectadmin1@cresta.co.bw or fax to 390 0635, ensuring your name is on the slip
Payment arrangements:
Date for effecting payment arrangements:
Payment arrangements/ Collection advice/ Other notes to Cresta Pride Connect Club:
Existing Cresta card number is:
I was referred to Cresta Pride Connect Club by:
Lead (office use only):






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