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SALES AGENT customer registration and order form


Sales Agent details (Please supply all your Agent details here)                                                  
                      Sales Agent number              
First name       Surname                                                                  
Customer’s details                          
          account number (if they have one)                        




Title Full name      
ID no.                           Date of birth                    
Street address for parcel delivery Postal code            


Postal address Postal code            
Home tel no.                         Cell no.                       E-mail  
Details of a friend or relative not living with you        
Title Full name Relationship  




Home tel no.                         Cell no.                       Alternative no.                            


Please fill in your order here                                                                                         Choose your preferred payment method  
                                                                                              below (Mark with an X)              


Code Product name / set description                                                                 Size   Col Qty       6x     12x 16x   Cash    
                                                                      months     months months      
Second choice: if your first option is out of stock           Choose your preferred payment method  
            below (Mark with an X)    
  Code  Product name / set description Size Col Qty     6x 12x 16x Cash  
  months months months  




                                          Please note that 12   month terms only apply to qualifying products.    
Employment details                                                                                                
                                                                    Self-employed n        
Employer/Company name                   Work tel no.                                            
                                                                          Pensioner n        
Position/Occupation                       Time spent in current job?                            
Income details                                                                                                
Gross monthly income from your main job before any deductions:   R                                                                                
Net monthly income that gets paid to you every month:   R                                                 Pay day (Day of month)        
Monthly income from other sources: Social Grants/Maintenance R                   Allowance from husband/wife/family R                          
      Commission/Overtime R                                 Selling products/goods R                          
Necessary monthly living expenses Rental income R                                                 Second job R                          
Total monthly living expenses*: Food R                   Accommodation R                       Transportation R              
(*Excludes Credit Card, Bond, Car Loan Water and electricity R                       Education R                           Medical R                
Repayment, Medical Aid payments) Maintenance R                           Other R                                                      
Monthly credit repayments                                                                                                
Total monthly credit repayments: R                                                                                              

Bank account details


Account holder’s full name______________________________________________ Bank ______________________________________________


Account number__________________________________ Account type_____________________________Branch code ______________________


To open an account with homechoice you need to supply proof of income. If you bank with Nedbank, Standard Bank or ABSA, they can, with your permission send us 3 months’ bank statements, at no cost to you.


I give homechoice permission to request 3 months’ bank statements from my bank.

If you wish to receive any of the following, please tell us by ticking the relevant box.      
Would you like the homechoice Group to inform you about special, time-limited offers on weekends and public holidays? YES NO
If you do not wish to receive any of the following, please tell us by ticking the relevant box:      
homechoice Group offers by: Phone SMS Email Offers from other select suppliers NO  

Cash or credit card payments


Upon receipt of this order, we will send the customer an SMS with the amount, due date and pay point information. The full amount must be paid as a bank deposit or EFT into the following bank account: FNB, Account No. 50050221924, Branch code 204109, before the goods will be dispatched. For faster processing, call 0861 422 4368 to receive a cash payment reference number before submitting the order form. This reference number must be filled in by the customer when making a cash deposit or credit card payment.


Sales Agents may not receive cash on behalf of customers.











call 0861 422 4368 (outside SA +27 21 680 1085), fax +27 21 680 1140 Customer Signature                      
salesagents@ – WhatsApp 0784002142 (RSA) (My signature confirms my order and serves                    
as confirmation that my income covers all my Date                  
Free SMS call back 36750 (RSA) 36666 (Lesotho) 45678 (Namibia) living expenses and credit commitments.)                  

You will receive full terms and conditions with your invoice and they are also available at homechoice.co.za. The instalments advertised include the interest charges of 21%, delivery fees of 9% of cash price (11% on furniture items) and a facility account fee. Note that we also charge a monthly service fee (currently R29) to your account. This is not included in the advertised instalment. Charges and fees will never exceed the limits prescribed by the NCA. Customers from Swaziland, Lesotho, Botswana and Namibia pay an extra international delivery fee. Your goods will be dispatched along with a Pre-Agreement & Quotation. Please note that we will require documents, such as 3 months’ payslips or bank statements, to validate your income for new credit accounts.

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