For office use only

Levy No.

Magisterial No.

Province

Chamber Code

Trade name

Name of

company/trust

Company

registration no

Fax no.

(     )

VAT registration no.

Tel. no.

(     )

Banking Details

Contact

person

Bank

Account no.

Branch

Type

Account holders name

E-mail

Postal address

Code

Physical address of

establishment

Magisterial district

Province

Full name(s)/partner/trustees/directors/members

Residential address

1

ID no

Tel

No

Cell

No

2

ID no

Tel

No

Cell

No

3

ID no

Tel

No

Cell

No

4

ID no

Tel

No

Cell

No

PARTICULARS OF OWN PENSION/PROVIDENT FUND (IF APPLICABLE) 

Name of fund

Name of fund

administrators

Tel/Fax

Date of inception

Registration No. of fund

SARS registration no of fund

Waiting period if any before employee may join the fund

Contribution rate employer

                %

Contribution rate employee

      %

Registration no. of vehicles used

Gross vehicle mass

Surname & initials of

employees

I.D. nos

Date

engaged

Category

code

Weekly

Monthly

wage

Trade

Union

member-

ship

Business commenced on

OFFICE USE

I hereby certify the above information to be correct.

1. Date of first contact

2. First Return-Month

3. Provident Fund

4. Employer Classification

Signature of employer

Date