Termination Point & Fibre Package Order Form

Unit Number -- Unit Number --001002003004005006007008009010011012013014015016017018019020021022023024025026027028029030031032033034035036037038039040041042043044045046047048049050051052053054055056057058059060061062063064065066067068069070071072073074075076077078079080081082083084085086087088089090091092093094095096097098099100101102103104105106107108108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200

Complex Name

First Name

Surname

ID/Passport Number

Mobile 1

Mobile 2

Email Address

Are you a Tenant/Owner? Are you a Tenant/Owner? Owner Tenant

Have you got a Termination Point (TP)? Have you got a Termination Point (TP)? Yes No

Would you like a Fibre Package? Would you like a Fibre Package? Yes No

Select a Router -- Select a Router --GigaHub (Single Band - Free Life Time Rental)GigaCentre (Dual Band - R150pm)

Select a Package -- Select a Package --Lite 5 (5 Mbps @R455pm)Surf 10 (10 Mbps @ R665pm)Flix 25 (25Mbps @ R907pm)Gamer 50 (50Mbps @ R1100pm)Family 100 (100Mbps @ R1412pm)Ultra 200 (200Mbps @ R2521pm)

When should you be activated? When should you be activated? As soon as possible I require to give my current ISP a notice period Date of my own choosing

How many days is your notice Period?

Date of Activation (dd/mm/yyyy)

I acknowledge that if I don't have a termination point, it will be at my expense to get one installed at R1500.00 I acknowledge that if I don't have a termination point, it will be at my expense to get one installed at R1500.00 Yes

I acknowledge the GigaHub modem/ONT with a package is free. I acknowledge the GigaHub modem/ONT with a package is free. Yes

I acknowledge there is a once-off connection fee of R1010.00. I acknowledge there is a once-off connection fee of R1010.00. Yes

I acknowledge that a pro-rated invoice is sent when the line is activated. I acknowledge that a pro-rated invoice is sent when the line is activated. Yes

I acknowledge that all monthly billing is due in advance. I acknowledge that all monthly billing is due in advance. Yes

I acknowledge that I have read the Terms and Conditions. I acknowledge that I have read the Terms and Conditions. Yes

I acknowledge that the line will be suspended with non-payment. I acknowledge that the line will be suspended with non-payment. Yes

I acknowledge that the owner of the unit has granted the tenant to get the termination point. I acknowledge that the owner of the unit has granted the tenant to get the termination point. Yes

I acknowledge that the tenant will be liable for the account. I acknowledge that the tenant will be liable for the account. Yes

Please supply the contact information of the owner here

I acknowledge that I have read the FAQ. I acknowledge that I have read the FAQ. Yes

I acknowledge that I have read the FAQ. I acknowledge that I have read the FAQ. Yes

How did you hear about us? -- How did you hear about us? --GoogleFacebookInstant MessageWord Of MouthField Agent