Fibre Internet Service Application Form
(this is a binding and legal document)
Sales Agent
Please Select
Desre vd Westhuizen
Stephanie van der Merwe
Website
Social Media
Google Search
Date
-
Month
-
Day
Year
Date
Primary Site Contact Details
Business Contact & Personal Information
Name and Surname
*
First Name
Last Name
ID Number
*
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Number
*
Please enter a valid phone number.
Email
*
example@example.com
Service Options
All pricing includes VAT @ 15%
Choose your Fibre Deal (select the tick box to activate your line item)
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( X )
Installation Option
1,725.00
ZAR
New Line M2M
Existing Line M2M
FTTH Subscription Selection
Monthly Recurring Fee
675.00
ZAR
OSLite_Up to 50/250Mbps Uncapped
Up to 50/50Mbps Uncapped
OSLite_Up to 100/50Mbps Uncapped
Up to 100/100Mbps Uncapped
OSLite_Up to 200/100Mbps Uncapped
Up to 200/200Mbps Uncapped
OSLite_Up to 300/150Mbps Uncapped
OSLite_Up to 500/250Mbps Uncapped
Wireless Router
a Wireless Router with a WAN port is required *Courier Fees applies for outlaying areas
795.00
ZAR
Payment Options / Bank Debit Order Instruction
Payment option
*
Monthly EFT
Debit Order
Bank Name
Account Name
Branch/Town
Branch Code
Account No
Type of Account
Current
Savings
Transmission
Bank Debit Order Authorisation
Bank Debit Order Authorisation: This signed Authority and Mandate refers to our contract as dated as on signature hereof ("the Agreement"). I / We hereby authorise Cyber South Datasecurity (Pty) Ltd to issue and deliver payment instructions to the bank for collection against my / our abovementioned account at my / our above mentioned bank (or any other bank or branch to which I / We may transfer my / our account) on condition that the sum of such payment instructions will never exceed my / our obligations as agreed to in the Agreement, and commencing on the commencement date and continuing until this Authority and Mandate is terminated by me / us by giving you notice in writing of no less than 20 ordinary working days, and sent by prepaid registered post or delivered to your address indicated above. The individual payment instructions so authorised to be issued must be issued and delivered as follows: (i.) On the last working day ("payment day") of each and every month commencing from the last working day of the current month. In the event that the payment day falls on a Saturday, Sunday or recognised South African public holiday, the payment day will automatically be the very next ordinary business day. Further, if there are insufficient funds in the nominated account to meet the obligation, you are entitled to track my account and re-present the instruction for payment as soon as sufficient funds are available in my account; (ii.) Monthly; on or after the dates when the obligation in terms of the Agreement is due and the amount of each individual payment instruction may not be more or less that the obligation due; (iii.) Annually; on or after the dates when the obligation in terms of the Agreement is due and the amount of each individual payment instruction may not be more or less than the obligation due; I / We understand that the withdrawals hereby authorised will be processed through a computerised system provided by the South African Banks and I also understand that details of each withdrawal will be printed on my bank statement. Each transaction will contain a number, which must be included in the said payment instruction and if provided to you should enable you to identify the Agreement. A payment reference is added to this form before the issuing of any payment instruction. I / We shall not be entitled to any refund of amounts which Cyber South Datasecurity (Pty) Ltd have withdrawn while this authority was in force, if such amounts were legally owing to Cyber South Datasecurity (Pty) Ltd. MANDATE I / We acknowledge that all payment instructions issued by Cyber South Datasecurity (Pty) Ltd shall be treated by my / our above mentioned bank as if the instructions had been issued by me / us personally. CANCELLATION I / We agree that although this Authority and Mandate may be cancelled by me / us, such cancellation will not cancel the Agreement. I / We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you. ASSIGNMENT I / We acknowledge that this Authority may be ceded to or assigned to a third party if the agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party. A cancelled, used cheque, copy of cheque, copy of bank statement or bank letter as proof of account should accompany the form to enable us to verify the bank details. I / We acknowledge that it is in my / our responsibility to notify Cyber South Datasecurity (Pty) Ltd in writing, notifying of the change of banking details before the 23rd of the same month in which the change took place. A penalty fee of R35.00 plus VAT will be added to unpaid / returned debit orders.
Herewith I declare that I am authorised to sign this Agreement.
Signed at
town
*
on date
Date
*
Signature
*
Submit
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