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Dial Up Service Application Form:
Only South African Residents may apply!!!
To print this form, click on the page and select Print Option
STEP ONE:

 

Full Name:

Business
  Name:

E-mail:
PO Box: Cell Phone:
Street Address:
City / Town: Code:
Home Phone: Work Phone:
Please enable the following service (s):
ADSL Account Options. Please make your selection. Number of dialups
 

Please Note: This service is not included free of charge if we are hosting your Website.
You will be charged an additional monthly fee for this service.
This fee will be added to your current account with Vanslife.com.

 You must accept our terms and conditions to make use of the service

Terms and Conditions of Service: 
 

PLEASE NOTE: CANCELLATION OF THIS SUBSCRIPTION MUST BE SUBMITTED IN WRITING VIA FAX OR E-MAIL WITH 1 MONTHS NOTICE. RECONNECTION FEES FOR FAILED DEBIT ORDER PAYMENT: R100.00

PLEASE NOTE:
Please ensure that all Information are provided before you click on the Submit Button!!!

 

or print this form and fax it to Fax Numbers: 017 714 0792 and 086 662 2662 or post it to P O Box 1164, Standerton, 2430
You must put your signature and the date in the space provided below:

Signature:

Date:

 

Terms of Service | Customer Support

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