Title
Mr
Mrs
Miss
Dr
Adv
Prof
Name
Surname
Cell Phone
Email Address
I accept the
terms and conditions
Step 1 of 2
Next
Gender
Male
Female
What is your closest major city?
Johannesburg
Pretoria
Cape Town
Durban
Bloemfontein
Port Elizabeth
Polokwane
Nelspruit
Kimberley
Upington
What is your current monthly household income?
Please select...
0-2499
2500-4999
5000-7499
7500-9999
10000-12499
12500-14999
15000-17499
17500-19999
20000-24999
25000-29999
30000-34999
35000-39999
40000-44999
45000-49999
50000+
What is your current employment status?
Please select...
Working full time
Working part time
Self-Employed
Retired
Student
Not currently employed
Do you have a valid driver's license?
Yes
No
Step 2 of 2
Next
Congratulations!
- You have now been entered into the draw -
Congratulations!
You have now been entered into the competition.