📞 +27 72 846 9644

✉️ info@secmed-africa.co.za

SPAZA SHOP REGISTRATION FORM

Business & owner information

Please complete all fields in CAPITAL LETTERS

Trading Name of Spaza Shop

Business Registration No. (CIPC, if applicable)

Date of First Trading

Day

Month

Year

Owner's Full Name & Surname

Owner's ID / Passport Number

Nationality

Asylum / Refugee Permit Number

Permit Valid Period

Valid From

Valid To

Contact Mobile Number

Contact Email Address

Emergency Contact Name

Emergency Contact Number

Physical Shop Address

Postal Address (if different)

Property Status

Ward Number

Number of Employees

BUSINESS TYPE

Spaza Shop Tuck Shop General Dealer Other

GOODS SOLD

Groceries Cold Drinks & Snacks Airtime & Data Fresh Produce Meat / Frozen Foods Bulk Supplier Food Outlet Other

COMPLIANCE DOCUMENTS ON FILE

Trading Permit Health Certificate Fire Safety Certificate CIPC Registration SARS Tax Number Landlord Consent Letter Approved Building Plan Pest Control Certificate of Acceptability (COA) Certified Asylum/Refugee Copy (Not Older Than 3 Months) Valid Lease Agreement

Operating Hours (Open)

Operating Hours (Close)

Preferred Inspection Day

Owner's Signature

Date

Official's Signature

On submit, a PDF copy of this form is generated and attached automatically — you'll be taken to a confirmation page once it's sent.

Business Desk · Spaza Shop Registration Form · Keep a copy for your records