CONNECTIVITY REQUEST FORM
Details
Title
Surname
Existing LocalNet Account (if any)
-select-
Miss.
Ms.
Mr.
Prof.
Dr.
Other
First Name
Initials
Date Service is required(dd/mm/yyyy)
ID/Company Registration Number
Company Name or Private Account
Postal Address
Physical Address
Code
Code
Code
Telephone Number (Business)
Code
Telephone Number (Home)
Code
Fax Number
Cell Phone Number
Service Required
ANALOGUE
ISDN 64K
ISDN 128K
ADSL
DIGINET
Monthly
R79
R115
R195
R260
R3 090
Bi-Annualy
R470
R690
R1 170
R1 560
R18 540
Annualy
R940
R1 380
R2 340
R3 120
R37 080
E-mail Details
E-Mail Name - 1st Choice
E-Mail Name - 2nd Choice
E-Mail Name - 3rd Choice
Extra E-Mail (R15/Month)
How Many
Extra E-Mail No.1 - 1st Choice
Extra E-Mail No.1 - 2nd Choice
Yes
No
-select-
1.
2.
3.
4.
5.
Extra E-Mail No.2 - 1st Choice
Extra E-Mail No.2 - 2nd Choice
Domain Name
Comments
* Required Fields
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