Benefit Card Application

Thank you for your interest in joining the Dis-Chem Benefit Programme. Please complete the form to apply and collect your card in-store. Alternatively register an online account and apply for a digital card.

Personal Details

First Name*

Last Name*

Identity/Passport Number*

Contact Details

Date of Birth*

Email Address*

Cellphone Number*

Telephone Number

Select a store (Physical card collection)*

Opt in for Marketing Communications

Are you currently pregnant?

Expected Due Date

Dependants

Details of Dependants Under 36 Months

Dependant #1

First Name

Last Name

Date of Birth

Dependants

Dependant #2

First Name

Last Name

Date of Birth

Dependants

Dependant #3

First Name

Last Name

Date of Birth

CUSTOMER CARE INFO

Feel free to reach out to our friendly Customer Care team:

Monday - Friday: 08:00am to 16:30pm

Saturday, Sunday and Public Holidays: Closed

Personal Details

Contact Details

Are you currently pregnant?

Details of Dependants Under 36 Months

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