Independent Service Provider Account Application Form

Is this a request for the creation of an Independent Service Provider that does not yet exist on the database?

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Category:

Independent Service Provider

Yes No
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Please select a value

Individual:

Title

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First Name

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Last Name

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ID Number

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Organisation:

Legal Entity Name

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Trading as

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Company Reg. No.

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VAT Reg. No.

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Natis No.

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RMI Reg. No.

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Enterprise No.

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Contact Person:

Title

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First Name

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Last Name

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Email Address

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Tel No.

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Fax No.

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Cell No.

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Physical Address:

Street/House No.

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City

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City Postal Code

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Country

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Banking Details:

Bank Name

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Bank Branch Code

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Account Number

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Account Holder

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Collection Authorisation

Yes No
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Postal Address:

P.O. Box

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City

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Postal Code

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Originator Details: [For Office Use Only]

First Name

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Last Name

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Department

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Tel No.

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Effective Date

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Date Requested

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Disclaimer:

I warrant that the information provided herein is to the best of my knowledge true, correct and complete.
I acknowledge that the submission of this form, will not automatically give me access to training and technical information of DTSA and that the application is subject to approval by DTSA.
I agree and understand that any approved application will be subject to the specific terms and conditions of the product/part/information I am intending to purchase/subscribe to.
I hereby consent to a credit check being conducted and consent to any further checks which may be required as determined by DTSA.
I hereby specifically consent to the sharing of my personal information to any DTSA Affiliate and/or Agent where required to fulfill the services.
I further specifically consent to the use of my / the company's Personal Information as provided herein for the purposes of this Agreement in line with POPIA, as well as for the purposes of marketing and Direct Marketing to me by DTSA or its affiliates.

I accept all the above statements.

Thank you, your details have been submitted someone will be in contact soon.

Your form could not be submitted due to technical difficulties. Please try again. If the problem persists, click here to submit via email (leads@daimler.com) or call us on +27 12 677 5544.

Independent Service Provider Account Application Form

Provider.

Cookies.

Privacy Statement.

Legal Notices and Terms.

Integrity and Compliance.

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Thank you, your details have been submitted someone will be in contact soon.

Your form could not be submitted due to technical difficulties. Please try again. If the problem persists, click here to submit via email (leads@daimler.com) or call us on +27 12 677 5544.

Independent Service Provider Account Application Form

Copyright

Provider.

Cookies

Cookies.

Privacy Statement

Privacy Statement.

Legal Notices & Terms

Legal Notices and Terms.

Integrity and Compliance

Integrity and Compliance.