4COS Global - The true recordable media specialist & PC Peripherals supplier

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The below application form is for South African region only. The (*) denote mandatory fields. Please ensure that the mandatory fields are cor-
rectly entered. Your Email address & other information provided will not be shared outside of K-Well.

User ID (*)

Province(*)

Password (*)

Comfirmed Password (*)

Postal Code(*)

Company Name(*)

Postal address(*)

Company Registered as:

City(*)

Nature of business(*)

Area Code

Telephone number(*)

Trading Name

Area Code

Facsimile Number(*)

Registration Number

Enter your comment/special request here(if is any)

Year Commenced Business(*)

VAT Registration Number

1.Kindly let us know where you heard about us?

Number of employees

2.Who is your target market?

Title(*)

3.What will be the estimated monthly activity of your trade facility
at K-Well?

First Name(*)

4.How do you find our website?

Family Name(*)

5.What is your average monthly purchase amount for peripherals
and blank media?

Designation(*)

Company URL (if is applicable)

Email(*)

Would you like to receive our newsletter & monthly
promotions via email?

Office address(*)

Thank you for your time in filling out this applicaion form. We will process your application and be in contact with you shortly. We sincerely we-
lcome you to be part of our dealership chain and participate in our wide range of product distribution.

Important Note: You should receive an automated acknowledgment from K-Well within one hour. If you do not receive one, it is possible that
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another folder such as junk, bulk, unknown, or trash.