Name:

Registration/ID: Select type of registrant Registration Number ID Number Passport Number

Business name/Trading As:

ERF Number:

Street No:

Street Name: *

Suburb: *

City: *

Province: Please select province The Western Cape The Eastern Cape The Northern Cape The Free state Gauteng North West Province KwaZulu-Natal Mpumalanga Limpopo

Area Code: *

Phone No: *

E-mail: * Invalid Email Format (e.g example@gmail.com / example@gmail.co.za)

Types of Liquor: Select types of liquor Beer Wine Spirits Traditional African Beer Combination: All types Combination: Beer / Wine Combination: Beer / Spirits Combination: Beer / Traditional African Beer Combination: Wine / Spirits Combination: Wine / Traditional African Beer Combination: Spirits / Traditional African Beer

Annual Turnover: Select annual turnover Less than R5 million Between R5 million and R15 million Between R15 million and R250 million Between R250 million and R1 billion More than R1 billion