You require a Mikrotik router to connect to our network ( R1995.00 inclusive of VAT)
Installation costs R500 excl VAT (includes fittings & fixtures, travel & setup). During installation, please ensure that the PC you will be using is on site. You will be asked to check that everything works to your satisfaction - and to sign off the install. If you have any difficulties thereafter, we are able to provide remote tech support.

To Proceed, please complete all steps. Feel free to call 0861 000 054 if you need assistance. On receipt of your application, we will conduct a geomatic survey before confirming your application.

As a first step, we need a signed copy of the quotation PLUS R1,000 security deposit, being 50% of the standard equipment cost). We schedule a suitable time for installation and you need to be present during the install to check that you are satisfied that all functions are working properly. You will be asked to sign off the installation and to pay for the balance of the equipment cost plus installation and first months fees.

Important Info regarding payments: The balance of 50% of the equipment cost PLUS the installation fee including any variations PLUS the first months fee, is payable on the day of installation - after which your account will be activated.

Your Account is a prepaid account. We process debit-orders on the 2nd-last working day each month. Bandwidth and telephone usage is billed at monthend and the debit orders for bandwidth & telephones set for the end of the first week each month - payable within 3 days.{print:[%br%]}}

Please tick the applicable option.

{tick:equip}	I already own equipment - please arrange a visit to check if it is suitable.
{tick:equip}	I want to purchase the recommended Mikrotik equipment,with remote support. Please draw up a Quotation for me to consider.
{tick:equip}	I want to RENT equipment @ R300 per month excluding VAT under a 12 month contract.

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{print:[%br%][%br%]} Name: {input:*name}{br} Company Name: {input:company} {print:[%br%]}

Postal Address: {text:postal_addr} Street Address: {text:*street_addr} ID or Passport Number: {input:*id_no} Current e-mail address: {input:*current_email}{br}

{print:[%br%]}

Telephone No Fax Number Code {input:*tel_code} Number {input:*tel_no}{print:[%br%]} Code {input:fax_code} Number {input:fax_no} Other requirements: {text:other} New e-mail address: {input:new_email} @easycoms.co.za {print:[%br%] [%br%] [%br%]} Additional email addresses are available @ R37.62 inclusive per month Please provide additional email addresses: 2nd email address: {input:email_2} 3rd email address: {input:email_3} 4th email address: {input:email_4}

{print:[%br%][%br%]} Please provide info on telephone services: {check:tel_info} I need a network switch to connect more than 1 PC: {check:nw_switch}

I accept the Easycoms terms & conditions {check:*accept_our_terms}{br}

Name (Debtor): {input:debtor} Signatory name: {input:sig_name}

Address: {text:do_addr} Signatory ID or Passport No: {input:sig_id_no} Contact Tel: {input:do_tel_no}

{br}{print:The details of my bank account are as follows:} {br}

BANK: {input:bank} BRANCH/TOWN: {input:branch} TYPE OF A/C: {select:acc_type|current|transmission|savings} ACCOUNT NAME: {input:acc_name} ACCOUNT NO: {input:acc_no} MONTHLY AMOUNT: R{do_amount}

{br}{print:I/we hereby request and authorize you to draw against my/our account with the above-mentioned bank (or any other bank or branch to which I/we may transfer my/our account) the sum of [$wordamount:do_amount$] (state amount in words) and/or any variable amount. All such withdrawals from my/our account by you shall be treated as though they had been signed by me/us personally. I/we the undersigned, "instruct" and authorize your agent Netcash (Pty) Ltd, to draw against my/our account. I/we understand that if bank details have been supplied the withdrawals authorized here will be processed by BankServ. I/we also understand that details of each withdrawal will be printed on my/our statement. I/We agree to pay any banking charges relating to this debit order instruction. I/we also understand that, should my debit-order fail for any reason, my services will be suspended and a penalty fee charged to my EasyComs account. I also agree that if my account is suspend due to being in arrears, that my services will be activated when my payment in full reaches EasyComs bank account. I will email proof of payment/s to admin@easycoms.co.za This authority may be cancelled by means of giving you thirty days notice in writing, sent by prepaid registered post, but I/we understand that I/we shall not be entitled to any refund of amounts, which you have withdrawn whilst this authority was in force if such amounts were legally owing to you. Assignment: I/We acknowledge that the party hereby authorized to effect the drawing(s) against my/our account may not cede or assign any of its rights and that I/we may not delegate any of my/our obligations in terms of this contract/authority to any third party without prior written consent of the authorized party. }

{br}{print:Signed _________________________________________ on this ______ day of ________________________ 2011}

{print:SIGNATURE AS USED FOR SIGNING CHEQUES OR CREDIT CARD VOUCHERS}

Thank you for completing the online application

The completed form will be emailed to the following email address:

{current_email}{br}

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Please enter the code exactly as you see it into the block below: {input:*captcha}

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Once you submit the application it will be prepared and emailed to you with instructions for sending it on to us..