TelkomSupporting documentation• Proof of identification (certified copy of SA ID or passport)• Copy of your most recent payslip and 3 months' bank statements• Copy of proof of residence (utility bill not older than 3 months)» For porting purposes, account number at donor/existing service provider required
Consumer Application Form
Agent to complete:
New application | j Contract renewal j I Transfer [_] Discontinue
Change of ownership Hj Date required L
Order No. T ! Account No.
Porting of mobile number j_ j Value-added services
Service required Fixed j ' Mobile j Convergence j i
ORIGINAL COPY
1. Customer details
Are you an existing customer? Yes f No j^J If yes, what is your existing telephone number?
First NamesTitle Surname
Passport Expiry Date MSA Citizen Yes 0 No 0 Identity/Passport No.
Gender M 0 F0 Dateof Birth 00000000
Marital Status Married [ | Single j j Divorced [ j Widowed [̂ j How are you married?* COP 0 ANC j [ ANC with accrual | [ Customary
How do you like to receive your invoice? Post [̂ Email! Email Address [_
n Off icerYour contact numbers Home Mobile Number
Physical Address Unit/Stand/Street [_
Postal Address Same as above 0 po Box/P Bag }
Friend or Relative Name and Surname
City Province
Contact Number
Select your preferred method of communication Email |_ j SMS j_ ] Telephone \_
Do you want your landline details in the phone book? Yes No
Postal Code
2. Employment details
Name of your employer j
Employer's Address
Suburb I
Occupation
City
CityPostal Address PO Box/P Bag
Period Employed J Years [ ^] Months Employer's Contact No.
Gross income per month | R
Province
Province
Postal Code
Postal Code
Net income per month |R Total monthly expenses R Household income IR
3. Banking details (debit order compulsory)
Should you not have sufficient funds in your account on the required due date, Telkom will make use of NAEDO to collect the arrears amount.
These collections will be at your cost.
Please debit my account in favour of Telkom SA SOC Ltd with my total amount due each month.
Branch NameBank Branch Code
Account Holder Name Account No.
Type of Account Cheque \_ | Transmission [_ ] Savings [_
Debit Dates 5th 0 10th0 15th0 20th Q 25th Q] Last day of the month | |Debit order maximum amount
Full Name Signature Date
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4. Change of ownership / Discontinuing your service
Change of ownership j~_ Discontinuing your service Q
Please provide your telephone numbers) to be changed to new owner [_ ~| & j^
Date for Change of Ownership 00! '•_ _1J0000 Final Invoice via Post0 Email 0 Email Address Q
Initials and Surname I i ID No. f
Reason for Discontinuance |
Physical Address Unit/Stand/Street |
Suburb 1
Postal Address Same as above ( j PO Box/P Bag |_
Contact numbers Home[
Signature (existing)
Date of Discontinuance 0 0 0 0 0 0 0 [1
Postal Code
Postal Code 0000
Q0000 Mobile Number 00[~~| 0 00j | |
Signature (new owner)
5. Your order/services
A. Fixed Line and Converged Products
How many ilnes do you require?
Do you want to use your existing line? Yes
When do you require your telephone service? [J
No Ifyes, what is the telephone number? |
Service provider of existing line (_
Fixed Stand Alone
Telkom Voice Line
Telkom Fixed Line look-alike
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DSI 1 inp =;r>pprl rpqnirpri
Splf-instnl!
rnllinrj Plnn
Internet
Converged Bundles
Fixed
LIE
3G
B. Mobile
Contract Period
Monthly
Monthly
Monthly
Frist
YPS
Monthly
Monthly
Contract Period
Monthly
Monthly
Monthly
0
i 1
0
120
120
120
Faster j
120
12 0
2*0
360
2,0
'
2* O
2, 0
2, 0
Fastest 0 Elite 0 Elite + [
2. | | Caliim
2, L
I '-••"
j '.; • - • . • ' • ;;i..:icd
36 | E ind
Package/Deal ID* Device Make/Model* Itemised Billing*
Yes0 No0
Yes0 No0
Yes0 No0
Yes0 No0
Yes0 No0
VAST* VAS2 Spend Limit* Contract Period
Total/minimum monthly cost*
"If no quote is done, these fields are all mandatory. Subject to credit management approval.
"VAS = Value Added Services
Authorised Signature Date
VI.0815 Page 2
C. Mobile, numbers to be ported to Telkom Mobile (Mobile and Convergence)
Account Classificationat DSP* Prepaid,
Postpaid or Hybrid
Account Type at DSP*Consumer or Business
DSP* Account no.at DSP* (Per
Invoice)
Account name atDSP* (Per Invoice)
Mobile Number RICA Person Name(Person RICA'd
at DSP*)
RICA PersonID/Company
Reg. No.
RequestedPort Date
YYYY/MM/DD
'(DSP = Donor/Existing Service Provider)
I, the undersigned, hereby confirm that I have been informed of the following and agree to these statements:
• I am porting to Telkom Mobile.
• I acknowledge that, in the event of Donor Service Provider rejection, my service will be activated with an 081 /061 Telkom Mobile MSISDN number.
• I acknowledge and accept that call credits/unused values from the Donor Service Provider are forfeited.
• I am responsible and liable for outstanding fees owing to the Donor Service Provider.
• I am responsible for all cancellation fees incurred when a cancellation request is received during the application process.
• Products and services offered at the Donor Service Provider might not necessarily be available at Tefkom Mobile.
• I have read, understood and hereby agree to the terms and conditions as set out in the application form.
Authorised Signature Date
6. Agreement
I declare, agree and confirm that:
1) If acting in a representative capacity, that I am duly and fully authorised to do so. I personally hereby indemnify and hold Telkom harmless for anydamages suffered by it, should it at any stage appear that I'm not so authorised.
2) The information supplied herein with regard to me and the Applicant is complete, true and correct as at date of signature/electronic processing hereof.
3) Electronic processing of the transaction (telephonically or via internet portal) will be binding on me and/or the Applicant as if I have signed a physicalapplication form, upon:a) my agreement via tick box and submission of the online application form; orb) my verbal confirmation of the existence of the agreement during the telephonic application process.
I (and/or the Applicant) am bound to the terms and conditions applicable to the transaction, including but not limited to:
a) Telkom's Standard Terms and Conditions for the Provision of Electronic Communication Services and Products (fixed-line services and products),available at http://www.telkom.co.za/general/termsandconditions/index.html; and/or
b) Telkom Mobile Subscriber Terms and Conditions (mobile services and products) available at www.telkommobile.co.za/terms/; and
c) product-specific terms and conditions related to the service and/or product I have applied for;
as indicated on any promotional material and/or on Telkom's official product website (www.telkom.co.za) and/or communicated to me telephonicallyduring a telephonic application process. I declare myself familiar with and bound to the content of said terms and conditions. All these terms andconditions are available online and will be made available to me in printed version or may be emailed to me, if I so request it.
Copy of terms and conditions Yes !_
Email soft copy to (~
Full Name
Print hard copy Yes [̂ ] No [
Signature Date
7. For office use only
Dealer Name
Campaign Name
Signature as Witness
Dealer Code
Sales No. ] Telkom Sales Representative
Date
Yes 0 No 0 Credit Limit f
RICA Information (required for mobile products):
Customer Representative as RICA Agent |_ RICA by Sales Agent RICA on Delivery Q
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