eDSL Order Form

Please fill in the information. Anything with a * next to it is compulsory. If you hit submit and the form doesn't submit, look out for the red text it will tell you what is wrong. Once you have fixed the errors, please submit it again.

Company name
Company Registration #
Company VAT #
First Name *
Surname *
Physical Address *
Suburb *
Code *
Postal Address
Code
Contact Number * - cell or work number
Fax Number
Contact eMail *
Phone Number to install ADSL on - blank if you need a line
What is the ADSL Line Speed Required *
What type of Bandwidth do you want? * - National means only SA websites available.
How much monthly bandwidth do you require? *
Do you want a Capped Service? * - Yes means pay per use, no means a fixed cap
You want to do a Self Install? * - you plug it in yourself, or we charge to do it.
Do you want a free ADSL router? * - Basic modem free with 1 year contract.(no Wifi)
Please enter your bank account details for debit order purposes
Name of Account Holder *
Name of Bank *
Branch Name *
Account Type *
Branch Code *
Account Number *
I have read and agree to the
terms and conditions *
Name Please leave this field empty.
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