Referred By
Personal Details
Name
Surname
Telephone Number
Fax Number
Email Address
Cellphone Number
Identity Number
Delivery Address
Postal Code
Customer Pack
Please Note:
The minimum order of 4 cases can be a mixture of the 500ml Screw Cap, 500ml Sports Cap and 1,5L Bottle.
Description
Minimum Order
Unit Price
Quantity
Total
500ml Screw Cap
Min 4 cases per month (12 per case)
R48
500 ml Sports Cap
Min 4 cases per month (12 per case)
R51
1.5L Bottle
Min 4 cases per month (6 per case)
R42
5L Bottle
Min 10 bottles per month
R11
20L Bottle (Empty – For Machine)
Min 2 bottles (once off)
R95
20L Bottle (For Machine)
Min 2 bottles per month
R42
*Delivery charges apply for all areas outside JHB/PTA. For a quote please email
info@balanced.co.za
.
TOTAL
Credit Card Details
Name on Card
Card Number
Expiry Date
3 Digit Code
Card Type
Please Select
Visa
Master
Amex
Diners
Debit Order Account Details
Banking Institute
Account Holder
Account Number
Branch Name
Branch Code
Account Type
Please Select
Savings
Cheque
Transmission
Authorisation
I hereby authorize HWW to debit my account with the amount required in respect of my subscription and agree that by giving this authorization I do not qualify for any refunds of amounts that have been debited in accordance with this agreement and herby agree to the terms and conditions as stated overleaf
Date
Bank Details
Account Name:
Health Wealth&Wisdom
Bank:
ABSA
Acc No:
4063576678
Acc type:
Cheque
Branch:
Eastgate
Code:
632005
