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Date: ___________________________

Received From: NEXCORE Design and Supply (Pty) Ltd  
Amount (in Rands): R____________________  
Payment Method: ☐ Cash   ☐ EFT   ☐ Other: ____________

For the supply of: ____________________________________________

Supplier Name: _______________________________________________
Supplier Contact No: __________________________________________
Supplier Signature: _____________________________  Date: _________

Received By (Company Rep): ____________________  Signature: ___________