Membership

Application Form

FSBBC Membership Application Form

Company Name *

MEMBERSHIP NO. (IF ANY)

FIRST NAME*

LAST NAME*

EMAIL*

CELL

TEL

POSTAL ADDRESS*

PHYSICAL ADDRESS*

MUNICIPAL DISTRICT *

Entity Type

Entity Size

INDUSTRY CLASSIFICATION

DESCRIPTION OF BUSINESS*

TOTAL NUBER OF EMPLOYEES*

WEBSITE ADDRESS (IF ANY)

UPLOAD COMPANY REGISTRATION CERTIFICATE*

UPLOAD BBBEE CERTIFICATE*

Bank
Bank Name	Standard Bank
Account Name	Free State Black Business Chamber
Account No.	240 290 550
Branch	Brandwag
Branch Code	051001