Click here to view a printable contract and registration form

Click here for the terms and conditions of the contract


Please fill in the form below if you wish to register with KMI.

Sponsor ID Number:
Sponsor Name or Company Name:
Sex: Male
Female
Contact Person if Company:
Daytime Phone Number:
Evening Phone Number:
Fax Number:
Date dd/mm/yyyy:
Kit: R430 kit
R740 kit
Applicant ID Number:
Date Of Birth dd/mm/yy:
Applicant Name (surname first):
Company Name (optional):
Spouse or Co-applicant:
Date Of Birth dd/mm/yy:
Mailing Address:
Email Address:
City:
Cell Phone Number:
Postal Code:
Daytime Phone Number:
Evening Phone Number:
Fax Number:
Reason For Enrolling (please tick one): Wholesale User
Retail
Business Builder
Bank:
Branch:
Branch Number:
Account Holder:
Account Number:
Credit Card: Master Card
Visa
Account Holder:
Credit Card Number:
Expiry Date:
CVV Number (last three digits on back of card):