Credit Application

Only for South African licensed venues / companies


    Company Information

    Registered Name:

    Trading Name:

    Company Registration #:

    VAT Registration #:

    Delivery Address:

    Postal Code

    Postal Address:

    Postal Code:

    Email Address:

    Telephone #:

    Contact Information

    Contact Person (Financial):

    Email Address (Financial):

    Contact Person (Orders):

    Email Address (Orders):

    Trade References

    Bank Details and Credit Limit



    Account #:

    Monthly Credit Limit Required:

    Names & Addresses of Directors / Members / Partners / Proprietors

    Full Name 1:

    Residential Address:

    ID #:

    Full Name 2:

    Residential Address:

    ID #:

    Full Name 3:

    Residential Address:

    ID #:

    Upload Documents

    Please upload a copy of the following files below in either PDF, JPG or PNG format:
    - Liquor License
    - Company Registration
    - VAT Registration
    - ID of owner/s

    (Combined maximum file size = 10MB)

    Drag & Drop Files Here

    Please wait for the document/s to finish uploading before pressing the submit button.

    To be signed by Director / Member / Partner / Authorised Signatory:

    On behalf of

    Hereby certify awareness of this application and authorise a consumer scan, judgment check with Kreditinform on the id numbers contained in this report and theopening of an account in the name of the above Company / Close Corporation / Partnership / Proprietorship, subject to the Terms & Conditions of Trading of Ataraxia Wines.

    Signed (Use your mouse cursor to sign here):



    • Please make sure all the details are 100% correct before submitting.

    If the form does not submit, please scroll up to see what needs to be corrected.