Customer Details Title First Name Surname Office Number Mobile Number Job Title Your Email Company Name Trading As Company Reg. No. VAT No. Business Type Public Co.(Pty) LtdProfessional Partner/Inc.GovernmentTrustNGOSole Proprietor Current Address Physical Address Is your postal address the same as your physical? YesNo Please enter your Postal Address Service Requirements SIP Lines Concurrent – Qtys Cloud PBX Extensions - Qty Number Porting? YesNo Current ISP & Bandwidth? Other Services Required? Describe: Hardware Requirements SIP Phones Desk – Qty SIP Phones Reception - Qty SIP Phones Cordless – Qty Conference Phone? YesNo Video Conference? YesNo Declaration I/We, the undersigned, confirm the accuracy of the information contained in this application and warrant that I/We am/are duly authorised to sign on behalf of the Subscriber. I/We acknowledge that I/We have read, understood and agree to be bound by the Subscriber's Standard Terms and Conditions upon signature hereof. I/We further acknowledge that the aforesaid Terms and Conditions have been made available by Wozacom (Pty) Ltd on the internet at www.wozacom.co.za. I/We hereby instruct Wozacom (Pty) Ltd to debit my/our bank account each month with the amounts which we are due and payable in terms of this agreement. I/We hereby consent to Wozacom (Pty) Ltd performing credit clearance verification.