North Coast 911 Registration Form

1
Company Name* This field is required.
2
Company Registration Number
3
Representative Name
First Name
Last Name
4
Office Number* This field is required.
Area Code
Phone Number
5
Mobile Number* This field is required.
Area Code
Phone Number
6
Number to use inside North Coast 911* This field is required.
Mobile Number
Office Number
Other
7
Phone Number* This field is required.
Area Code
Phone Number
8
Email* This field is required.
example@example.com
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Website Address
10
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
Company Logo
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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12
Membership Benefits:

PLATINUM PROMO (NC911)

Exclusive button featuring your company logo.

Listing inclusion in the Local services page under "Specific Category" services.

Customized page with website integration. If you do not have a website we will create a landing page for you.

WhatsApp Integration

Virtual Card. This will allow users to save your contact details to their device in one click.

Company QR code.

Get directions, Call office or mobile number button.

10 strategically chosen keywords integrated into the North Coast local service section for direct access to your page

1 x Flyer design

Custom advert crafted and shared across social media platforms with your provided link.

Push Notification sent to all active subscribers notifying them of your listing.

Initial setup fee: R1500

Standard fee for 12 months before promo: R499

Promotional monthly service and hosting fee till 30 November 2024 @ R100 per month, there after R349 per month.
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Membership Options* This field is required.
NC911 Promo @ R100 pm till November 2024 thereafter R349 pm
Silver @ R299 pm x 12 months
Gold @ R399 pm x 12 months
Platinum @ R499 pm x 12 months
14
My Promo Code* This field is required.Please enter NC911 as your promotional code.
15
Account Holder Details* This field is required.
First Name
Last Name
16
Type of Identification* This field is required.
ID Number
Passport Number
17
ID Number* This field is required.
18
Passport Number* This field is required.
19
Date of Birth* This field is required.
20
Transaction option* This field is required.
I acknowledge that I will receive an Invoice each month
21
I accept that there is an activation fee of R 1500.00* This field is required.
I Accept
22
Optimize your SEO's even more for an additional - 10 Keywords @ R 200.00 pm* This field is required.
Yes
No
23
Your Premium including VAT is:
24
Marketing Agency Name (If Applicable)
North Coast 911
25
Agent Name
26
Invoice Date* This field is required.
1st
15th
25th
27
By signing and clicking Submit I fully acknowledge that I have read, understood and accept the terms and conditions of North Coast 911 Local Services. North Coast 911 Local Services is a product of Local 911 (PTY) Ltd.

Local 911 (PTY) Ltd and any 3rd party Services will not be held liable for any change in Emergency Numbers, Loss of signal or any features within the app that is not functioning because of poor reception.
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* This field is required.
29
Signature
30
Date Signed
Should be Empty: