Distributor Registration - Safe LP Gas Disitributors Network South Africa

Distributor Registration

Please complete the form below to register. Once you have registered you are able to complete your profile by adding your logo and banner image. You will also receive additional instructions via email in the user account email address you supply.

Membership Registration
Business Information
*
Distributor For?
AfroxEasiGasOryxTotalGasOther
Please check at least one option.
Please enter valid data.
*
Registered Company Name
Please add your company name
Please enter valid data.
*
Trading As Name
Add your Trading As name - Even if the same
Please enter valid data.
*
Business Registration Number
Please add company registration number
Please enter valid data.
VAT Number
Please add your VAT number
Please enter valid data.
Please enter at least 10 characters.
Maximum 10 characters allowed.
Business Physical Address
Complex Name
Please Add Complex Name
Please enter valid data.
*
Street Number and Name
Please add Street Name and Number
Please enter valid data.
*
Suburb
Please Add Suburb
Please enter valid data.
*
City
Please Add City
Please enter valid data.
*
Province
Select OptionEastern CapeFree StateGautengKwaZulu-NatalLimpopoMpumalangaNorthern CapeNorth WestWestern Cape
Please Add Province
Please enter valid data.
*
Business Telephone Number
Please Add Business Number
Please enter valid data.
Directors/Owners Details
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Full Name
Add Directors Name
Please enter valid data.
*
Surname
Add Directors Surname
Please enter valid data.
*
ID Number
Please add ID Number
Please enter valid data.
Please enter at least 13 characters.
Maximum 13 characters allowed.
*
Cell Phone Number
Please Add Cell Phone Number
Please enter valid data.
Please enter at least 10 characters.
Maximum 13 characters allowed.
*
Email Address
Please Add Email Address
Please enter valid data.
Please enter at least 5 characters.
Documents Supply
*
CK1 Registration Certificate from CIPC
Please Add CK1 Registration Certificate
Invalid file type selected.
Invalid file type selected.
Max 2MB File Size - pdf, jpg, png, gif, doc, docx
*
SARS Confirmation of Tax Registration
Please Add Confirmation of Tax Registration
Invalid file type selected.
Invalid file type selected.
Max 2MB File Size - pdf, jpg, png, gif, doc, docx
*
Premises & Flammable Substance Certificate
Please Add Flammable Substance Certificate
Invalid file type selected.
Invalid file type selected.
Max 2MB File Size - pdf, jpg, png, gif, doc, docx
*
Certificate Expiry Date
Please select date.
Invalid Date.
Flammable Substance Certificate Expiry Date
Certificate of Conformity
Please select file.
Invalid file selected.
Invalid file selected.
Max 2MB File Size - pdf, jpg, png, gif, doc, docx
User Account Information
This is the information you will use to sign into your account
*
First Name for Account
First Name can not be left blank.
Please enter valid data.
This first name is invalid. Please enter a valid first name.
*
Last Name for Account
Last Name can not be left blank.
Please enter valid data.
This last name is invalid. Please enter a valid last name.
*
Email Address For Account
Email Address can not be left blank.
Please enter valid email address.
Please enter valid email address.
This email is already registered, please choose another one.
*
Username for Account
Username can not be left blank and cannot have any spaces
Please enter valid data.
This username is already registered, please choose another one.
This username is invalid. Please enter a valid username.
No Spaces Please - This will be used to sign you in
*
Password for Account
Password can not be left blank.
Please enter valid data.
Please enter at least 6 characters.
Please keep it strong - You will need this to sign in
    Strength: Very Weak
    Additional Information
    Declaration

    The applicant confirm, that the information and documentation supplied in support of this application, is correct, to the best of my knowledge.

    The applicant further warrants that if the information supplied in this application changes at any time during the period of Membership with The Safe LP Gas Distributors Network, the applicant will immediately notify the Network of such change.

    Protection Of Personal Information Act

    The Safe LP Gas Distributors Network of South Africa confirms that the information and documents supplied in this application may be deemed personal information in terms of the Protection of Personal Information Act 2013 (POPI ACT) and we will accordingly take all reasonable steps to ensure that the information is processed / used / stored in accordance with the POPI Act and for the following reasons only:

    • To evaluate the compliance level of the applicant in terms of all provisions and regulations as required by law,

    • To verify the information and all documentation disclosed herein against any available source.

    Terms Acceptance

    Please read and accept the code of conduct by clicking below. Once you read through it you can complete the registration process.

     
    CLICK TO OPEN CODE OF CONDUCT

    I have read and agree to all the terms in the code of conduct.
    Signed by :

    *
    Name & Surname
    Text field can not be left blank.
    Please enter valid data.
    ID Number
    Please Add ID Number
    Please enter valid data.
    *
    Position
    Please Add Your Position
    Please enter valid data.
    Confirms that I have the legal right to act on behalf of the company
    *
    Date
    Please select date.
    Invalid Date.
    *
    I accept all terms in the Code of Conduct
    Yes, I Accept
    Please accept the terms
    Please enter valid data.
    REGISTER & PAY NOW