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):
Dialup Type
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
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:
