SUBSCRIBER APPLICATION FORM
Please complete all required fields
Full Name
*
First Name
Surname
Gender
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SA ID / Passport number
enter full identification number
Phone Number
*
-
Area Code
Phone Number
E-mail
example@example.com
Employment details
please complete all fields
Name of employer
Occupation
Employers telephone number
-
Area Code
Phone Number
Gross monthly income
Salary before deduction
Home fibre internet packages
Please select the package that best suits your internet needs
Home fibre internet
*
10/2Mbps R599pm on M2M
10/2Mbps R898 on 12months
10/2Mbps R798 on 24months
10/2Mbps R748 on 36months
10/10Mbps R799pm on M2M
10/10Mbps R1098 on 12months
10/10Mbps R998 on 24months
10/10Mbps R948 on 36months
20/2Mbps R949pm on M2M
20/2Mbps R1248 on 12months
20/2Mbps R1148 on 24months
20/2Mbps R1098 on 36months
20/20Mbps R999pm on M2M
20/20Mbps R1298pm on 12months
20/20Mbps R1198pm on 24months
20/20Mbps R1148pm on 36months
50/5Mbps R1049pm on M2M
50/5Mbps R1248pm on 12months
50/5Mbps R1148pm on 24months
50/5Mbps R1098pm on 36months
50/50Mbps R1099pm on M2M
50/50Mbps R1398pm on 12months
50/50Mbps R1298pm on 24months
50/50Mbps R1248pm on 36months
Please select your package
Contract term and installation fee
*
Free-12 Months
Free-24 Months
Free-36 Months
R2499-M2M
Please select your contract term
Proposed Installation date
-
Month
-
Day
Year
Debit order details
Customer information
*
First Name
Surname
Bank name
Bank account details
Branch Code
Account Number
Debit order date
last working day of the month
15th
25th
Authorised Signature
*
comments
Please refer 4 of your friends that needs internet service:
Full Name
Address
Contact Number
1
2
3
4
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