LOCALWEB SUBSCRIPTION & DEBIT AUTHORIZATION FORM

PLEASE RETURN THIS ORIGINAL TO P.O. BOX 303 EMPANGENI 3880

AND FAX TO LOCALWEB INTERNET 035-7922017 TEL.035-7922017

ACCOUNT DETAILS
Account Name (for companies):
Surname:

Postal Address:
First Name:
Mr./Mrs./....:
Cell Number

Postal code:
Phone: O/H(          ) -

Fax: (           ) -

SERVICE OPTION (Prices include VAT)

Service Option
(please tick)

Description

Monthly Subscription

Annual Subscription
(   ) ISDN Dial-up Browsing and E-Mail for business Most Popular Business Service with unrestricted internet access on ISDN and 5 e-mail addresses R 199.00 R 2189.00
(   ) Dial-up and E-mail Popular Service for Home or Business with 5 E-Mail addresses R 99.00 R 1089.00
(   )Own Domain Own Domain Name and Web site R 120.00 R 1440.00
(  )LAN Browser &ISDN For Local Area Networks or Fast ISDN R 299.00 R 3289.00

PAYMENT OPTIONS
Tick the payment option required. Please note that the subscription component of your account will be billed in advance, and any excess usage will be charge monthly in arrears. A R 20.00 penalty applies to collect unpaids.

AUTOMATIC DEBIT ORDER  AUTHORIZATION
I hereby authorize Sontek Consultants c.c., t/a LOCALWEB, to process debit transactions on my account as, specified, for payments relating to my subscription to the internet and technical support received.

FOR DIRECT DEBIT ORDER PAYMENTS
Bank & Branch: Acc type:

Date

 Bank Clearing code:
 

 

 Acc no:

Acc. Name:
I.D. no.:

Signature

                                    E-mail Name(s) and  Password(s)

Internal use

E-mail Name 1st.   :

Account Code:

 E-mail Name 2nd. :
E-mail Name 3rd.   :

Introduced by:

 E-mail Name 4th.   :
E-mail Name 5th.   :

PLEASE NOTE : This subscription is subject to a 60 DAY written notice on cancellation