Cannafrica Gateway

Cannafrica Onboarding Information Sheet

Consumer Data Privacy Disclaimer

Cannafrica (Pty) Ltd respects your right to privacy and will not share your personal information with any third party unless required by law. Your information will be used only to register you in our customer database so that we can verify your identity; maintain accurate records; dispense products safely and legally; provide quality service and support; research and analytical purposes (in anonymised form where possible).

By completing this form, you consent to the collection and use of your information for these purposes.

POPIA Compliance

Your personal information is processed in line with the Protection of Personal Information Act (POPIA). You may request access, correction, or deletion of your data or withdraw consent where legally possible.

Personal Details

Are you a South African citizen?

Yes No

Title

First Name

Surname

Race

African White Coloured Indian Other

Gender

Male Female Other

Cellphone Number

Email Address

Identification & Location

ID/Passport Number

Date of Birth

ID/Passport Document

Please upload a clear photo of the front side of your ID or passport.

Upload / Drag & Drop a file

PNG, JPG, PDF up to 10MB

Branch

Country of Residence

Health History

Age

18-25 26-30 31-40 41-50 51-60 60+

Weight

Height

<1.6 m 1.6-1.7 m 1.7-1.8 m 1.8-1.9 m 1.9-2.0 m 2 m+

Health History

Cancer Pain Anxiety Depression Insomnia Seizures ADHD

Are you on chronic medication?

Yes No

Income

Submission

Please click for the terms and conditions

By signing this form, I confirm that I have read and understood all terms and conditions of the study and hereby provide my full informed consent. Please provide a signature.

Signature

I accept

Yes No

Unfortunately, you cannot be admitted if you do not consent.