Operator Registration Form

Registered Trading Name (CIPC) *

Trading As Name *

Registration Number (CIPC): *

Vat Number *

Which license type do you have? *

Operation Licence Number: *

Issued by the regulator

Which provincial regulator licensed you? *

Start Date Of Operation: *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Contact Person *

First

Last

Email *

Email

Confirm Email

Phone *

Number Of Employees *

Number of Branches *

Gross Gambling Revenue Amount: *

Phone