1157 Schoeman Street Forum Building, Suite 4 Hatfield PO Box 11774, Hatfield, 0028
Tel: 087 351 8217 Fax: 086 550 5760 nxavoip@nqaluv.co.za www.nqaluv.co.za
Nxatel Business Solution. Reg No: 2008/086692/23 Vat 4630251488 Directors: NT Dontache, LP Mabunda
VoIP Subscriber Agreement Customer Contact Details Company Name
Trading As
Reg. Number
VAT Number
Telephone Number
Fax Number
Postal Address
Customer Order Number
Installation Address Sales contact
Cell
IT contact
E mail
Cell
Invoicing Contact
Cell
Rates per minute (billed per second) Local
40c
Hardware fee p/m
National
55c
ADSL p/m
Mobile
R 1,25
International Numbers of ports required
Bandwidth Fee p/m
Country Dependant @ R65,00 per port X ________
Other: Initial term (months) R
Total amount for ports
Total amount for contract
SIGN HERE Customer Authorised Signature/s Declaration & Acceptance I, the under signed confirm the accuracy of the information contained in this application and warrant that I am duly authorized to sign on behalf of the company stipulate above. I acknowledge that I have viewed, read and understood the Nxatel (NxaVoIP) terms and conditions made available to me by Nxatel Business Solutions on their website at www.nqaluv.co.za. I further acknowledge that I, agree to be bound by these terms and conditions upon signature hereof.
Name (Customer)
Customer Authorised Signature/s
Signed at
Designation (Customer)
Date
Nxatel Authorised Signature
SIGN HERE
Mandatory Debit Order Authorisation We request that Nxatel Business Solution or its cessionary draw against our bank accounts, where it may be, the amounts due in terms of this agreement and all Schedules thereto.
SIGN HERE
Customer Authorised Signature/s Bank
Branch Code
Account Number
Name of Acount
*Please note of the following Once-off connection Fee R300
Upfront Payment of phone usage
R
(exl Vat)
Office Use Only SIP NO: 087 ______________________________ Application Checked By:_____________________ Authorised By: ____________________________
__________/___________/_______________ Account Activation date Account No:VN00 ________________________X
Nqaluv Group Š2008
Upfront Usage received: _____________________ R300,00 cleared All Supportive docs received Authorised Signature:________________________