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THE X-TRA LIFESTYLE LOYALTY PROGRAMME ADDS UP TO REAL MONEY BACK IN YOUR POCKET Member Application NEWS HEADLINES! Wednesday, June 01, 2011 Mozambique Holiday Win 7days accommodation for 6 people at a... ADVERTISEMENT To become an Xtreme Loyalty member please read the following instructions carefully: Download the application form here. (Adobe Acrobat Viewer Required) Complete it and fax it to us. To access your account information and to be elegible for competitions, register on the website using the form below. Please note that this online account will only be activated once your application form has been submitted and approved. You will be notified by email to the address entered in the form below when your account has been activated. Please note: all fields are required (*), you will not be able to submit this form untill all the fields are completed. Please fill in the following details Select Region: Select Region Lowveld * Title: Sequence Number: * First Name: * Surname: Card Number: (ONLY required if you already have your card and have not signed up for online membership.) * Gender Male Female * ID Number * Date of Birth 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 * Cell Phone: Prepaid Contract * Telephone Number * Cell Number (username for login) * Password * Confirm Password Fax Number * Occupation * E-mail Address * Postal Address * Postal Code * Partners you would like to see on the program? * Receive advertising info via: SMS    E-Mail    © 2012 Xtreme Loyalty. All Rights Reserved. Designed & Developed by Fyre Interactive