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Eureka Beperk
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* Indicates required question
Naam en Van
Name and Surname
*
Your answer
Selfoon nommer
Cellphone Number
*
Your answer
Epos Adres
Email address
*
Your answer
Waar woon u tans?
Where do you currently live?
*
Your answer
Gee u ons toestemming om u te kontak?
Do you give us permission to contact you?
*
Yes
No
Het u nog u aandele sertifikaat vanaf Eureka?
Do you still have your share's certificate from Eureka?
*
Yes
No
Wat was u lid nommer?
What was your member number?
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Your answer
Wat was die datum(s) toe u in Eureka belê het?
What was the date(s) when you invested in Eureka?
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MM
/
DD
/
YYYY
Wat was die kostes/ waarde wat u ingedien het vir Eureka?
What were the costs/ value that you submitted for Eureka?
*
Your answer
Het u enige bewyse van die transaksies?
Do you have any proof of these transactions?
*
Yes
No
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