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First Name *

Last Name *

Billing Company (optional)

Billing Address Line 1 *

Billing Address Line 2 (optional)

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Billing State (optional) Select an option…Eastern CapeFree StateGautengKwaZulu-NatalLimpopoMpumalangaNorthern CapeNorth WestWestern Cape

Billing Country (optional)South Africa

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Billing Phone *

Shipping Company (optional)

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Shipping Address Line 2 (optional)

Shipping City (optional)

Shipping State (optional) Select an option…Eastern CapeFree StateGautengKwaZulu-NatalLimpopoMpumalangaNorthern CapeNorth WestWestern Cape

Shipping Country (optional)South Africa

Shipping Postcode (optional)

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VAT Number (optional)

Name of salon/store *

Address of salon/store you intend on distributing Lashmint *

Contact number for salon/store *

Do you want us to add you onto our website as a stockist so that clients can easily find you? (optional)

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