MWEB ADSL Promotion Application Form

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Store / Reseller informationRetail Store/ResellerMWEB Connect (Pty)Ltd100 Fairway CloseCape Town 7463Reg: 1996/015134/07VAT: 4390165688Customer No:MWEB Authorisation:Product/Promo Code:BranchOffice useSales Person NameTel. NumberCUSTOMER DETAILS :ADSL 12 Month InternetSubscription ContractNew MWEB subscriber detailsWhat would you like your new MWEB email address to be?1st choice2nd choice@mweb.co.za@mweb.co.zaEmail address must be between 3-12 characters. Onlyletters and numbers are allowed.PasswordPassword must be 6-8 characters long and include lettersand numbers. You can change it later online.Personal detailsDetails of individual applicant, or business representative.TitleBusiness detailsYou only need to fill this in if you are applying for an account in thename of a business. The business representative must also fill in all theirpersonal details in the left column.First namesSurnameID/passportnumberHome phoneBusiness nameRegistrationnumberEmailLandlineWork phoneFaxCellphoneFaxResidentialaddressCellphonePhysicaladdressPostcode:Postcode:Postal addressPostal addressPostcode:Postcode:Please sign your initials hereon every page
MWEB Connect (Pty)Ltd100 Fairway CloseCape Town 7463Reg: 1996/015134/07VAT: 4390165688Customer No:MWEB Authorisation:Product/Promo Code:Office useCUSTOMER DETAILS...continued (Page 2)Payment detailsAccount holderAccount numberAccount type Current TransmissionSavingsOtherChequeBankBranchBranch codePlease debit my bank account as shown in favour of MWEB CONNECT(PTY) LTD with the total amount owing by me as specified in thisagreement.DateSignatureDon't forget to sign!Please sign your initials hereon every page
Page 5 and 6: MWEB Connect (Pty) Ltd100 Fairway C
Page 7 and 8: MWEB Connect (Pty) Ltd100 Fairway C
Page 9: PART B: CAPPED PRODUCTS (Section 8
Page 12 and 13: 11.3 MWEB takes reasonable steps to
Page 14 and 15: levels of traffic sufficient to imp

MWEB ADSL Promotion Application Form

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