Thank you for your loyalty and continued support! Please complete this form to request your product package after completing 10 months of subscription. Please note that if you have not made a minimum of 10 payments, your request will be rejected.

Your Information

Your First Name and Surname

First

Last

Your Cell Number

Your Email

Your Subscription Details

Your Start Date of Subscription:

For how many Months have you subscribed?

Your Membership Package Selected

Total Amount You Paid in Rands

Your Delivery

Your Physical Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

This is where your package will be delivered

Your Preferred Delivery Date & Time

Date

Time

We will do our best to deliver on this date and time. Please allow AT LEAST 24 HOURS!

Special Requests or Notes (if any)

Please or Your

Declaration & Agreement

I confirm that I have completed 10 months of subscription and am eligible to request my product package as per the membership terms and conditions. I acknowledge that my request is subject to verification and approval.

Please tick to agree

I agree to the above Declaration

Your Signature

Clear Signature

Please sign with your finger or stylus pen