Full Name

E-mail

Age

Contact Number

Landline Number

TOTAL Cash available to invest (Rand amount)

Your own (free) cash available to invest (Rand amount)

Funds you will borrow (Rand amount)

Number of stores interested in

When do you plan to open your first store?

Who or where will you borrow funds from?

Interest - list the area(s) in which you would like to open a store(s)