Fillable Consumer Application Form (Law for All South Africa)

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Consumer Application Form (Law for All South Africa)

On average this form takes 39 minutes to complete

The Consumer Application Form (Law for All South Africa) form is 3 pages long and contains:

  • 0 signatures
  • 63 check-boxes
  • 128 other fields

Country of origin: SOUTH-AFRICA
File type: PDF

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Agent to complete:
New application
Change of ownership
Porting of mobile number
Service required Fixed
Mobile
Convergence
Campaign name
Order no.
Account no.
System customer ID.
Supporting documentation (new customer)
• Proof of identification: Copy of SA ID or
passport (including work permit)
• Copy of your most recent payslip and
three months’ bank statements
• Copy of proof of residence (utility bill not
older than three months)
• For porting purposes, account number at
donor/existing service provider required
Supporting documentation
(existing fixed/mobile customer)
• Proof of identification: Copy of SA ID
or passport (including work permit)
Sections to complete
New application: 1, 2, 3, 5A or 5B, 6
Change of ownership: 1, 2, 3, 4, 5A, 5B, 6
Porting: 1, 2, 3, 5A, 5B, 6
2. Employment details
Name of your employer
Occupation
Employer’s address
Suburb City Postal code
Employer’s contact no. Period employed Years
Months
Gross income p/m
Net income p/m
Total expenses p/m
Household income p/m
3. Payment detail (debit order compulsory)
Please debit my account in favour of Telkom SA SOC Ltd with my total amount due each month.
Bank Branch name Branch code
Account holder name
Account no.
Type of account Cheque Transmission Savings
Debit order maximum amount
Debit dates 15th 25th Last day of the month
Should any debit order be returned unpaid on the due date, Telkom and/or its authorised debt collection agencies will have the right
to make use of NAEDO to collect the arrears amount. These collections will be at your cost.
Full name Signature Date
1. Customer details
Are you an existing customer? Yes No If yes, what is your existing number?
Title
Surname First names
SA Citizen Yes No
Identity/Passport no.
Passport
expiry date
Gender M F
Date of birth
Contact details Home no.
Office no.
Mobile no.
Email address
Physical address Unit/Stand no/Street
Suburb City Postal code
Postal address Same as above PO Box/P Bag
Suburb/City Postal code
How do you like to receive your invoice? Email (Compulsory for all broadband services) Post (Additional charges may apply)
V160211 Page 1
Consumer Application Form
4. Change of ownership (existing owner’s details)
Number(s) to be changed
&
Change of ownership date
Initials and surname ID no.
Contact details Home no. (new)
Office no.
Mobile no.
Final invoice Email
Email address
Post
Postal address
Suburb City Postal code
Signature (existing owner) Signature (new owner)
5. Your order/services
A. Fixed-line and converged products
How many lines do you require? When do you require your telephone service?
Do you want to use your existing line? Yes No
If yes, what is the telephone number?
Service provider of existing line
Do you want your landline details in the phone book? Yes No
Fixed stand-alone
Calling plan (voice service)
Telkom Broadband service Yes No Contract period 24 Months Monthly
Technology/Speed
Lite*
Fast
Faster
Faster +
Fastest
Elite
Elite +
Fibre 100*
* Lite is not available on Fibre. Fibre 100 is not availalble on DSL.
(Factors that can affect your speed may include: distance from the exchange to your home; peak internet usage times; the number of people sharing your broadband connection within your home; or you may have
reached your Telkom Internet SoftCap.)
Internet plan
Self-install Yes No
(Installation charges applicable for month-to-month contracts)
Device add-on
VAS add-on
Family Circle service Yes No Telkom mobile no. 1 Telkom mobile no. 2
Telkom mobile no. 3 Telkom mobile no. 4
Converged bundles
Bundle description Technology Contract period
B. Mobile products
Spend limit (Over and above monthly subscription; subject to credit management approval) R150 R300 R1000 No limit
Insurance Yes No
Band
Monthly premium
Corporate preferential deal/self-pay Yes No
Telkom SA SOC Ltd is an authorised Financial Service Provider, FSP number: 46037, underwritten by Mutual & Federal Risk Finance Ltd, a member of the Old Mutual Group.
I/We have purchased the Telkom Cellular Insurance and hereby declare that it was done on a non-advice basis. Non-advice in respect to a purchase means that the Telkom
Representative did not provide advice, did not make a recommendation, nor provided guidance or made a proposal of a financial nature in respect to Telkom Cellular Insurance.
Telkom Cellular Representative presented the benefits and features of Telkom Cellular Insurance, which allowed me to make an informed decision of my/our own.
Full name Signature Date
Package/deal ID Device make/model Itemised billing Additional value-added services Contract period
Yes
No
Yes
No
Yes
No
V160211 Page 2
(Cancellation within six months may be subject to
payment of a reasonable setup cancellation fee)
6. Agreement
I (and/or the Applicant), being the undersigned, 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 any damages suffered by it, should it at any stage appear that I’m not so authorised.
2) The information supplied herein with regard to me 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 as if I have signed a physical
application form, upon:
a) my agreement via tick box and submission of the online application form; or
b) 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:
1) Telkom’s standard terms and conditions for the provision of electronic communication services and products (fixed-line services and
products), available at www.telkom.co.za/sites/aboutus/regulatory/termsandconditions/
2) Telkom’s mobile subscriber terms and conditions (mobile services and products) available at
www.telkom.co.za/sites/aboutus/regulatory/termsandconditions/
3) 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 telephonically during a
telephonic application process. I declare myself familiar with and bound to the content of said terms and conditions. I hereby
consent to Telkom credit-vetting this application.
All these terms and conditions are available online and will be made available to me in printed version or may be emailed to me, if I so request it.
Do you require a copy of the terms and conditions? Yes No If yes, or
Email address
Full name Signature Date
7. For office use only
Dealer name
Full name Signature Date
RICA information (required for mobile products): RICA by sales agent RICA on delivery
B2C delivery address: Customer address Employee address
C. Mobile numbers to be ported to Telkom mobile (mobile and convergence)
Account
classification
at DSP* prepaid,
postpaid or hybrid
Account type
at DSP
*
consumer
or business
DSP
*
Account no.
at DSP
*
(per invoice)
Account
name
at DSP*
(per invoice)
Mobile number RICA person name
(person RICA’d
at DSP*
)
RICA person
ID/Company
reg. no.
Requested
port date
YYYY/MM/DD
I, the undersigned, hereby confirm that I have been informed of the following and agree to these statements:
1. I am porting to Telkom mobile.
2. I acknowledge that, in the event of donor service provider rejection, my service will be activated with a 081/061 Telkom mobile number.
3. I acknowledge and accept that call credits/unused values from the donor service provider are forfeited.
4. I am responsible and liable for outstanding fees owing to the donor service provider.
5. I am responsible for all reasonable cancellations fees incurred when a cancellation request is received during the application process.
6. Products and services offered at the donor service provider might not necessarily be available at Telkom mobile.
7. I have read, understood and hereby agree to the terms and conditions as set out in the application form.
Signature Date
V160211 Page 3
*(DSP = Donor/Existing Service Provider)
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Consumer Application Form (Law for All South Africa)

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Completed 15 July 2021

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