Southern Africa Logo Southern Africa Map Logo Distributor Application Form

You are about to apply for listing as an distributor.

Please fill in as many details as possible before submitting the form.

Distributor Categories: (Tick all that apply)
Community Distributor - Distribute as a commuinity service.
Commercial Distributor - Sell for profit.
O E M Distributor - Include with new or upgraded computers.

Please note that only individuals can be listed as community distributors.

Company Name:

Contact Name:

Public eMail Address:
eMail address that will appear on this site (if applicable).

Contact eMail Address:
eMail address for mailing list / communication subscriptions.

Website URL:
Web URL to appear on this website (if applicable).

Telephone Number:

Cellular / Mobile Number:

Your Province / Country:

Nearest major city or town.


Full Postal Address:

Notes or Other Details:
Please provide any details you feel relevant.

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