All fields marked with an asterisk (*) are required
Section A: Customer Information
Full registered name of business: *
Trading name of business:
Application Type: *
Cash
Credit
ID Number/Passport Number:
Contact Email Address:
Phone number: *
Contact Name: *
Preferred contact method: *
E-mail
SMS
Delivery Address
Delivery Contact Name: *
Street name and number*
Find My Location
Building / Shop / Centre: *
Street name and number: *
Closest street corner of (CNR):
Suburb: *
City / Town: *
Postal Code: *
Delivery Phone number:
Province: *
Botswana
Eastern Cape
Free State
Gaborone
Gauteng
KwaZulu-Natal
Limpopo
Mpumalanga
Manzini
Namibia
Northern Cape
Nigeria
North-West
Western Cape
Confirm your map pin location
Please confirm that the map pin below is in the correct location. If not, then manually move it to the correct position or amend the GPS coordinates
Format Type
Google
Garmin
Latitude
Longitude
Latitude (eg S 23 12.1234 or N 80 24.2345)
Longitude (eg E 123 12.1234 or W 11 24.2345)
Section B: Clover Office Use
Rep Name: *
Rep Code: *
Delivery Branch Name: *
Delivery Branch: *
Delivery Day: *
SUN
MON
TUE
WED
THU
FRI
SAT
Call Day: *
SUN
MON
TUE
WED
THU
FRI
SAT
Route Number: *
Key Account Code: *
Submit