City wireless order form

City wireless order form
Name*

First NameLast Name
ID or Passport number*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Payment method*

EFTDebit order
Installation: Free Ruijie Router: R780

1)Installation and router payable within 24 hours of installation.

2)Pro-rata services to be paid within 24 hours of receiving the invoice.

3)Setup fee of R2100.00 will only be clawed back in full if service is cancelled within 12 months(Bank details below)

4) All Monthly Subscriptions are due in advance and by the 5th of every month
Invoice made out to
optional (for business)
Vat number
Optional (For business)
Please tick your chosen package below*

4mbps @ R480pm (Best for a single user)6mbps @ R680pm (Best for small families)8mbps @ R780pm (Recommended)10mbps @ R980pm (Best recommended)20mbps @ R1356.80pm (Best of the Best)
Signature*

Clear
Capitec Business Account
Account Name: Blaze Internet
Acc Number: 105 453 9600
Type: Cheque / Current
Branch Code: 450105
Should be Empty: