Apply For Workmen's Compensation Workman’s Compensation Registration 1APPLICANT INFORMATION2COMPANY INFORMATION3EMPLOYEES INFORMATION4UPLOAD DOCUMENTS5REVIEW UPLOADED DOCUMENTS6REVIEW COMPLETE APPLICATION7SUBMIT APPLICATION EmailThis field is for validation purposes and should be left unchanged.Application IDApplicant informationName and surname*Applicant E-mail address* Cell number* Company informationCompany/CC Name*Company/CC Registration Number*Company/CC AddressPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Business DescriptionPAYE Number (if applicable)UIF Number (if applicable)Number of Directors*0123456789101112131415Director 1Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 2Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 3Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 4Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 5Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 6Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 7Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 8Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 9Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 10Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 11Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 12Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 13Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 14Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Director 15Name and surname*E-mail address* Contact number*Resident of South Africa Yes No SA ID number*Passport number*No of shares issued to DirectorPhysical address* Address Line 1 Address Line 2 City State Zip Code Postal Address* Same As Physical Address Street Address PO Box Private Bag Street Address* Address Line 1 Address Line 2 City State Zip Code PO Box* Number Post Office Province Postal Code Private Bag* Number Post Office Province Postal Code Employees InformationNumber of employees*OneTwoThreeFourFiveSixSevenEightNineTenElevenTwelveThirteenFourteenFifteenSixteenSeventeenEighteenNineteenTwentyEmployee 1Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 2Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 3Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 4Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 5Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 6Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 7Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 8Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 9Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 10Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 11Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 12Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 13Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 14Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 15Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 16Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 17Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 18Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 19Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year*Employee 20Employee name and surname*Resident of South Africa? Yes No SA ID Number*Passport Number*Employee start date* DD slash MM slash YYYY Employee salary*Estimated total earnings of employees for the year* Do you want to upload documents?* Yes No Documents Upload* Drop files here or Select files Accepted file types: jpg, gif, pdf, doc, docx, xls, xlsx, Max. file size: 2 MB, Max. files: 5. Allowed Formats: jpg, gif, pdf, doc, docx, xls, xlsx Max File Size of Each Document Should be 2MBMax Number of Files Allowed is 5Documents Required as Below:1. Company documents2. Director/Member certified ID copiesPlease Note: If these files are too large to upload, please send it to info@registeryourbusiness.co.za, using your Company/ CC name as the subject. Do you want to review your uploaded documents?* Yes! I want to see my uploaded documents No, I don’t want to see my uploaded documents Click on below link to preview your uploaded documents {Image Format Upload:266} Do you want to review your application?* Yes! I want to review my application No, Its Fine Please Review Your Application As Below {all_fields} Submit ApplicationI confirm all information to be true and correct in all aspects and I agree to the registration terms and conditions. Yes No Would You Like COID Registration and Letter of Good Standing?*COID Registration – R2100.00 COID Registration and Letter of Good Standing – R3200.00 No Yes Total payableTotal R0.00 Payment Method* EFT Credit / Debit Card Banking Details Bank:FNBAccount Name:Register Your BusinessAccount Number:627 1367 7493Branch Code:250 655
