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Nico Fourie
Riana Gagiano
Wagieda van Rensburg
Justin van Rensburg
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20L Weekly Delivery
Retail Order
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Retail Order
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Order Section
Captain Splash 350m Still
Unit Price: R7.70
Case of 24 - R185.00
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- select quantity -
1 Case - 24 Bottles
2 Cases - 48 Bottles
3 Cases - 72 Bottles
4 Cases - 96 Bottles
5 Cases - 120 Bottles
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750ml Still
Unit Price: R11.08
Case of 24 - R266.00
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1 Case - 24 Bottles
2 Cases - 48 Bottles
3 Cases - 72 Bottles
4 Cases - 96 Bottles
5 Cases - 120 Bottles
6 Cases - 144 Bottles
7 Cases - 168 Bottles
8 Cases - 192 Bottles
9 Cases - 216 Bottles
10 Cases - 240 Bottles
11 Cases - 264 Bottles
12 Cases - 288 Bottles
13 Cases - 312 Bottles
14 Cases - 336 Bottles
15 Cases - 360 Bottles
16 Cases - 384 Bottles
17 Cases - 408 Bottles
18 Cases - 432 Bottles
19 Cases - 456 Bottles
20 Cases - 480 Bottles
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1,5lt Still
Unit Price: R21.20
Case of 12 - R150.00
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- select quantity -
1 Case - 12 Bottles
2 Cases - 24 Bottles
3 Cases - 36 Bottles
4 Cases - 48 Bottles
5 Cases - 60 Bottles
6 Cases - 72 Bottles
7 Cases - 84 Bottles
8 Cases - 96 Bottles
9 Cases - 108 Bottles
10 Cases - 120 Bottles
11 Cases - 132 Bottles
12 Cases - 144 Bottles
13 Cases - 156 Bottles
14 Cases - 168 Bottles
15 Cases - 180 Bottles
16 Cases - 192 Bottles
17 Cases - 204 Bottles
18 Cases - 216 Bottles
19 Cases - 228 Bottles
20 Cases - 240 Bottles
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5lt Still
Unit Price: R21.20
Case of 5 - R106.00
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- select quantity -
1 Case - 5 bottles
2 Cases - 10 bottles
3 Cases - 15 bottles
4 Cases - 20 bottles
5 Cases - 25 bottles
6 Cases - 30 bottles
7 Cases - 35 bottles
8 Cases - 40 bottles
9 Cases - 45 bottles
10 Cases - 50 bottles
11 Cases - 55 bottles
12 Cases - 60 bottles
13 Cases - 65 bottles
14 Cases - 70 bottles
15 Cases - 75 bottles
16 Cases - 80 bottles
17 Cases - 85 bottles
18 Cases - 90 bottles
19 Cases - 95 bottles
20 Cases - 100 bottles
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10lt Still
Unit Price: R40.00
Case of 5 - R200.00
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- select quantity -
1 Case - 5 bottles
2 Cases - 10 bottles
3 Cases - 15 bottles
4 Cases - 20 bottles
5 Cases - 25 bottles
6 Cases - 30 bottles
7 Cases - 35 bottles
8 Cases - 40 bottles
9 Cases - 45 bottles
10 Cases - 50 bottles
11 Cases - 55 bottles
12 Cases - 60 bottles
13 Cases - 65 bottles
14 Cases - 70 bottles
15 Cases - 75 bottles
16 Cases - 80 bottles
17 Cases - 85 bottles
18 Cases - 90 bottles
19 Cases - 95 bottles
20 Cases - 100 bottles
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Order Total
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[{"field":"order_type","logic":"equal","value":"Retail Order","and_method":"","field_and":"","logic_and":"","value_and":""}]
20L Weekly Delivery
Contact Person
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Contact Person Phone Number
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Email Address
Your E-mail Address
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Delivery Address
Street address
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Complex Name & Number
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Complex Name & Number
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City/Town
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Postal Code
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Delivery Schedule
Preferred delivery day
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Monday
Tuesday
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Friday
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Preferred Delivery Time
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Delivery Notes (optional)
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Order Section
Choose Plan
Basic
- R150/month
1x 20Lt Container per week
Standard - R300/month
2x 20Lt Container per week
Premuim
R450/month
3x 20Lt Container per week
Premuim
R600/month
3x 20Lt Container per week
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1 Container Deposit
(Refundable when contract is terminated)
1 Container Deposit
[{"field":"{20Lt_Plan}","logic":"equal","value":"150","and_method":"","field_and":"","logic_and":"","value_and":""}]
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2 Container Deposit
(Refundable when contract is terminated)
2 Container Deposit
[{"field":"{20Lt_Plan}","logic":"equal","value":"300","and_method":"","field_and":"","logic_and":"","value_and":""}]
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3 Container Deposit
(Refundable when contract is terminated)
3 Container Deposit
[{"field":"{20Lt_Plan}","logic":"equal","value":"450","and_method":"","field_and":"","logic_and":"","value_and":""}]
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4 Container Deposit
(Refundable when contract is terminated)
4 Container Deposit
[{"field":"{20Lt_Plan}","logic":"equal","value":"600","and_method":"","field_and":"","logic_and":"","value_and":""}]
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Amount Due
Monthly Amount:
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Amount Due
First Payment Incl Deposit:
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[{"field":"{order_type}","logic":"equal","value":"20L Weekly Delivery","and_method":"","field_and":"","logic_and":"","value_and":""}]
Customer Signature
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Customer confirms order details are correct.
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For Marketing Purposes - Optional
Current Water Supplier
(Optional)
None (new customer)
Municipal / Tap Water
Another Water Delivery Company
Supermarket Bottled Water
Borehole / Filter System
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Estimated Weekly Water Usage - 20lt containers
(Optional)
1 – 2 20L Containers
3 – 4 20L Containers
5 – 6 20L Containers
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[{"field":"{order_type}","logic":"equal","value":"20L Weekly Delivery","and_method":"","field_and":"","logic_and":"","value_and":""}]
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