{print:[%br%][%br%]} Full Name of Person Responsible: {input:*name} Company Name: {input:company} {print:[%br%][%br%]} ID or Passport Number: {input:*id_no} Company Registration No. : {input:co_reg} {print:[%br%]}

Postal Address: {text:postal_addr} Street Address: {text:*street_addr} VAT Registration Number: {input:vat_no} E-Mail Address: {input:*current_email}{br}

{print:[%br%]}

Telephone No Cellular Number Code {input:*tel_code} Number {input:*tel_no}{print:[%br%]} Code {input:cell_code} Number {input:cell_no} Fax No Code {input:fax_code} Number {input:fax_no}{print:[%br%]}

{print:[%br%][%br%]}

I understand that service runs on the O-Tel service and that I will be allocated a local telephone number. I will need to give people my own allocated number to receive Incoming calls. {print:[%br%]}Voice mail is available 20MB per user. Prices are calculated per minute, below Telkom rates. My telephone service runs on my EasyComs Wireless-DSL internet access package, OR on any ADSL line - see std application on www.easycoms.co.za I understand and agree that:{print:[%br%]} The recommended ip-phone is the SNOM300+ (supplied by EasyComs){print:[%br%]} I agree to a setup fee for activating the line and account (R228 Incl){print:[%br%]} This agreement will continue on a month to month basis and must be cancelled with two full calendar months written notice.{print:[%br%]} Monthly line rental = R114.00 payable in advance of each month{print:[%br%]} My account will be set up & activated when EasyComs receives my completed application. Proof of payment will be emailed to admin@easycoms.co.za OR faxed to 086 604 8159 in the amount of R456.00 inclusive.{print:[%br%]} My Calling Plan starts with R20 and I understand that I need to top this up and have a credit balance to make calls. I can visit my telephone console to check the status of my account, where detailed reports can be viewed or printed.{print:[%br%]} If the monthly fees are deducted by debit order, please make sure there are funds in the account to cover the payment. The debit-order payments are deducted on the second-last working day of each month, unless another date is requested.{print:[%br%]} All correspondence will be mailed to your EasyComs email address, unless specified otherwise.{print:[%br%]}

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

Name and Surname of the person responsible for account: {input:debtor}

Postal Address: {text:do_addr} 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} BRANCH CODE: {input:branch_code} ACCOUNT NAME: {input:acc_name} ACCOUNT NO: {input:acc_no} TYPE OF A/C: {select:acc_type|current|transmission|savings} {br}{print:

I/WE HEREBY REQUEST AND AUTHORIZED YOU TO DRAW AGAINST MY/OUR ACCOUNT WITH THE ABOVEMENTIONED BANK (OR ANY OTHER BANK OR BRANCH TO WHICH I / WE MAY TRANSFER MY / OUR ACCOUNT) THE SUM OF R[$formatamt:do_amount$] (STATE AMOUNT IN WORDS) [$wordamount:do_amount$]. AND OR ANY VARIABLE AMOUNT PERTAINING TO THIS AGREEMENT, ON THE 1ST WORKING DAY OF EACH MONTH. This being the amount necessary for settlement of the monthly due to you in respect of our purchases /contract. All such withdraws 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 authorized 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. This authority may be cancelled by means of giving you thirty (30) days notice in writing, sent by prepaid register post, but I / we understand that I / we shall not be entitled to any refund of amount, which you have withdrawn this authority whilst this authority was in force if such accounts were legal 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 OBLIGATION IN TERMS OF THIS CONTRACT / AUTHORITY TO ANY THIRD PARTY WITHOUT PRIOR WRITTEN CONCENT OF THE AUTHORIZED PARTY. I 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.

[%br%] Signed _________________________________________ on this ______ day of ________________________ 2012

SIGNATURE AS USED FOR SIGNING CHEQUES OR CREDIT CARD VOUCHERS [%br%][%br%]}{br}

Full Name of signatory: {input:sig_name} ID Number: {input:sig_id_no}

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..