SALES CODE:

iBurst Subscriber Service Contract
Tel: 012 665 1936 | Fax: 086 641 7348
E-mail: tyron@gtconnection.co.za

 

SUBSCRIBER DETAILS

 

Subscriber / Business Name

*

ID / Company Reg. No

* email or fax proof of identification 

Physical Address

*

 

CODE  

*

Postal Address

*

 

CODE  

*

Contact Person / User

*

Telephone No

Fax No

Cell No

*

Website

Existing E-Mail

*Type none if you do not have any

 

 

* Please complete

 

 

SERVICE PLAN DETAILS

 

 

 

Package        

   1 GIG

   3 GIG

   6 GIG

   9 GIG

 

 

 

 

 

Option 1        30 day notice account and purchase the iBurst device cash

 

 

 

 

 

     Monthly Subscription

R 469 / month

R 599 / month

R 899 / month

R 1099 / month

     Desktop Device (USB with Ethernet Port)

R2 800 once-off

     Notebook Device (PCMCIA Card) 

R2 100 once-off

    Already have Device

 

 

     Activation Fee

R 114   once off

Option 2        24 month Rental (incl Monthly Subscription and Hardware)

 

     Notebook (PCMCIA Card)

R 579 / month

R 679 / month

R 1009 / month

R 1209 / month

     Desktop (USB with Ethernet Port)

R 599 / month

R 699 / month

R 1029 / month

R 1229 / month

 

 

 

 

 

     Activation Fee

R 456   once off

 

 

 

 

 

SUBSCRIBER ACCOUNT DETAILS

 

 

  

 

  

 

Username 1 (preferred)

*

Password

*

 

 

 

 

Username 2

*

 

 

 

 

 

 

Pass phrase question

* IE: What is your dog's name?

Pass phrase answer

* IE: Skippy

 

 

 

 

How did you hear about us?

* About IBurst...

 

 

 

 

 

 

SUBSCRIBER REFERENCES

 

 

 

 

  

 

Account reference 1

*

Telephone number

*

 

 

 

 

Account reference 2

Telephone number

 

 

 

 

 

 

BILLING DETAILS

 

 

 

 

BANK ACCOUNT DETAILS *

 

                                               

   

Bank

Account Name

* IE: J Smith

Branch Name

Account No

Branch Code

Account Type

  

 

 

CONFIRMATION

 

 


*I/We, the undersigned, confirm the accuracy of the information contained in this document and warrant that I am duly authorised to sign on behalf of the subscriber. I acknowledge that I have read, understand and agree to be bound by the terms and conditions annexed hereto. I hereby authorize WBS to debit my bank account / credit card with the amounts which are due and payable in terms of this Agreement. I hereby consent to WBS performing a credit check on me/us if 24 month contract is selected.