Mgababa Connect - Application Form

Applicant Information

Business/Customer Name

Registration/ID Number

VAT Number

Installation Address

Street Name

Province

City/Town/Suburb

Postal Code

Landline

Cell Phone Number

Email Address

Attach ID Copy

Attach Proof of Address

Attach 3 Months Bank Statement

Service Selection

H1 = R299 (Up to 3Mbps DL / 3Mbps UL)

H2 = R499 (Up to 5Mbps DL / 5Mbps UL)

H3 = R699 (Up to 7Mbps DL / 7Mbps UL)

B1 = R999 (Up to 10Mbps DL / 10Mbps UL)

B2 = R1999 (Up to 20Mbps DL / 20Mbps UL)

B3 = R2999 (Up to 30Mbps DL / 30Mbps UL)

VOIP Services

SmartVoice

LTE SIM Data

Porting Required

Cloud PBX

Porting Number

Debit Order Mandate

Account Holder Name

Address

Bank Name

Branch Name

Branch Number

Account Number

Type of Account

Date of Debit Order Run

Contact Number

Debit Amount

Contract Reference Number

Acknowledgement

I/We confirm that the information provided in this application is true and correct to the best of my/our knowledge. I/We acknowledge that I/we have read, understood, and agree to the Terms and Conditions available at www.mgababaconnect.co.za.

I accept the declaration and agree to the Terms and Conditions.

Date

Applicant Signature (Draw below):

Mgababa Connect Representative Signature (Draw below):

Wireless Internet Application Form

Applicant Information

Service Selection

VOIP Services

Debit Order Mandate

Acknowledgement