CYMOT Loyalty Card Application Form
Name
Mr.
Mrs.
Prefix
First Name
Last Name
ID Number
*
Contact Number:
*
Email
*
example@example.com
Are you applying for a new card or replacing an old card?
*
New card
Replace old card
What type of Loyalty Card do you want to apply for?
*
Please Select
Farmers Loyalty Card
SME Loyalty Card
Taxi Loyalty Card
Back
Next
Application for Loyalty Card
Farm Name:
*
P.O.Box:
*
District:
*
Region:
*
Email:
*
Please upload a copy of the Farm Registration / Meat Board registration or similar:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload a copy of your ID:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Business Name
*
Registration Certificate Number:
Postal Address of Owner:
*
Postal Address of SME (if different from owners details):
Street Address:
*
Town:
*
Region:
*
Please attach a copy of the Business Registration:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please attach a copy of your ID:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Taxi Permit Number:
*
Vehicle Registration Number:
*
Postal Address:
*
Street Address:
*
Town:
*
Region:
*
Please attach a copy of Taxi Registration:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please attach a copy of your Taxi Permit:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please attach a copy of your ID:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Select the CYMOT Branch you want to collect your Loyalty Card:
*
Windhoek City Centre
Windhoek Katatura
Windhoek Northern Industrial
Windhoek Prosperita
Tsumeb
Rundu
Oshakati
Grootfontein
Otjiwarongo
Swakopmund
Walvis Bay
Lüderitz
Rosh Pinah
Keetmanshoop
Gobabis
*
I hereby declare that the information above is correct
*
I hereby declare that the information above can be used for the purpose of the Loyalty Card Application
I hereby allow CYMOT to add me to their Newsletter
Please verify that you are human
*
Submit
Should be Empty: