Wireless Car Protector Application Form

Wireless Car Protector Application Form

Trekit365 Reg No:2017/009089/07
Please complete the form below to signup for a Wireless Car Protector. Note that installation is done at any one of our workshops.
Personal Information
First NameLast Name
ID Number / Passport Number*
Phone Number*
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Payment Options

Please select the payment option below.
OPTION: 1
prevnext( X )
UPFRONT ONCE-OFF PAYMENTI will pay prior to the installation
1,300.00ZAR

Total

0.00ZAR
OPTION 2

I WILL PAY AT THE WORKSHOP (NB: We do not receive cash at the workshop)
Vehicle Details (1)
Make*
Model*
Engine Number*
Vin Number*
Year
Car Color
License Plate Number*
Vehicle Details (2)
Make
Model
Engine Number
Vin Number
Year
Car Color
License Plate Number
Client's Signature*

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

Personal Information