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Application Form

 

YES, I wish to join Diners Club Connoisseurs.

Put us to the test! Your first six months’ membership of Diners Club Connoisseurs is free. Thereafter the annual membership is R59 which will be debited to your Diners Club card.

Once you are a member you will receive a range of quality products throughout the year.

Membership is 100% guaranteed.

Tell us about yourself:

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COFFEE CORNUCOPIA  
Choose your grind:
Choose your frequency:
Each Coffee package includes 6 packs of coffee, but you can select to receive additional packages (6 packs).
E.g. If you indicate 1 extra package, you will receive 12 packs of coffee.
Please indicate extra quantity:
   
OLIVE OIL OBSESSION  
Choose your selection:
   
* FIRST NAME
* SURNAME
* INITIALS
* TITLE
*ID NUMBER:
* TELEPHONE (HOME)
TELEPHONE (WORK)
FAX NUMBER
* MOBILE NUMBER
* E-MAIL
* DELIVERY ADDRESS
* POSTAL CODE
* POSTAL ADDRESS
* POSTAL CODE

Your Payment Details

* DINERS CLUB CARD NO.
* CVV NO   (last 3 digits on back of card)
* EXPIRY DATE
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