Air stream wireless order form

Name*

First NameLast Name

Company name

optional (for business)

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

ID Number*

Email*

example@example.com

Invoice made out to

Optional (For business)

Vat number

Optional (For business)

Payment Method*

Debit OrderEFT

Phone Number*

Please enter a valid phone number.

Installation: Free Ruijie router: Free to use

1) Pro-rata services to be paid within 24 hours of receiving the invoice. (Bank details below)                                                   &#13;&#10;2)Set up fee of R2180.00 will only be clawed back in full if service is cancelled within 12 months&#13;&#10;3)  Please note that the CPE and Pole remain the property of Blaze Internet.&#13;&#10;4) All Monthly Subscriptions are due in advance and by the 5th of every month

Please tick your chosen package below*

20mbps@ R580.00 pm50 mbps@ R780.00 pm80mbps@ R880.00 pm

Signature

NEDBANK ACCOUNT DETAILS:
Account Name: Crimson Moon Trading CC
Account Number: 1069761036

Branch Code: 198765

Thank you for your valued business!
BLAZE INTERNET

Air stream premium wireless