Independent Wifi and IPTV Provider

Application Form

Supporting Documentation

• Proof of identification: Copy of SA ID or passport (including work permit)

Example of ID (Please ensure that signature and date is clearly visible)

• Copy of proof of residence (utility bill not older than three months)
• Copy of proof of bank account

**All Fields with * are mandatory**

Upload ID *

Click or drag a file to this area to upload.

Upload Proof of Residence *

Click or drag a file to this area to upload.

Upload Proof of Bank Account *

Click or drag a file to this area to upload.

I prefer to WhatsApp these documents

I prefer to WhatsApp these documents

Please check this box & Whatsapp to: 064 767 4128

1. Customer Details

Title *

Surname *

First Names *

SA Citizen *

Yes
No

Gender *

M
F

ID no. *

Passport no.

Passport expiry date

Contact Details

Home no.

Office no.

Mobile no. *

Alternate Mobile no.

Email *

Physical Address

Unit / Stand / Street Name and No *

Erf no.

Suburb *

City *

Postal Code *

Postal Address

Postal Address

Same as above

PO Box / P Bag *

Suburb / City *

Postal Code *

Delivery Address

Unit / Stand / Street Name and No *

Erf no.

Suburb *

City *

Postal Code *

How do you want to recieve your invoice?

Email (compulsory for all broadband services)
Post (Additional charges may apply)

2. Employment Details

Company Name *

Company's Contact no *

Company Address *

Suburb *

City *

Postal Code *

Gross Income p/m *

Net Income p/m *

Total Expenses p/m *

Household Income p/m *

3. Your Internet Plan

Please Choose your Fibre Package *

4. Payment Details

How would you like to pay your monthly bill? *

EFT (Banking details on monthly bill)
Debit Order

Your account will be debited as stated below. *

Debit Order

EFT Dates *

5th
15th
20th
25th
Last day of the month

Please debit my account in favour of Telkom SA SOC Ltd with my total amount due each month.

Telkom SA SOC Ltd will not share, use or disclose any information other than stipulated in our privacy policies.

Bank *

Branch Name *

Branch Code *

Account Holder Name *

Account no. *

Account Type *

Cheque
Transmission
Savings

Debit Order Maximum Amount *

*Minimum of 2½ times the monthly fee.

Debit Order Dates *

5th
15th
20th
25th
Last day of the month

Should any debit orders be returned unpaid on the due date, you will be liable for a debit order rejection fee. In addition, Telkom and/or its authorised debt collection agencies will also have the right to make use of NAEDO to collect the arrears amount, and you will also be liable for these collection costs.

5. Agreement

Click Here to Accept our Terms & Conditions *

I Accept

By clicking "I Accept" you confirm that you have read our Privacy Policies and agree to our Terms & Conditions.

Call today for no-obligation FREE consultation

064 767 4128

www.fibremax.co.za

info@fibremax.co.za