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Consumer Application Form

Hi there!

Supporting documentation (new customer)

  • Proof of identification: Copy of SA ID or passport (including work permit)
**Please ensure all fields are filled in

Branch: Homecloud - Virtual

Sales Person: Promotions @Homecloud

Please choose a package type

Title

Surname

First Name and Second Name

SA citizen Yes No

ID no. Passport no.

Passport Expiry Date

Gender
Male Female

Date of birth

Contact details: Home no.

Office no.

Mobile no.

Email

Physical address Unit/Stand/Street name and no.

Suburb

City

Postal code

Delivery address Unit/Stand/Street name and no.

Suburb

City

Postal code

Postal address Same as above Yes No

PO Box/P Bag

Suburb/City

Postal code

How do you like to receive your invoice?

Email (Compulsory for all broadband services) Yes No

Post (Additional charges may apply)
Yes No


Name of your employer

Occupation

Employer's Address

Suburb

City

Postal Code

Employer’s contact no.

Gross income p/m

Net income p/m

Total expenses p/m

Household income p/m


Please debit my account in favour of Telkom SA SOC Ltd with my total amount due each month.

Bank

Branch name

Branch code

Accountholder name

Account no.

Type of account: Cheque Transmission Savings

Debit-order maximum amount (Please allow 2½ times your monthly fee)

Debit Dates:
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


Mobile Products

Package/Deal ID

Device make/model

Itemised billing

Additional Value-added services

Contract Period

Yes No
Insurance:
Yes No
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 of 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 of 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


I, 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:
    1. my agreement via tick box and submission of the online application form; or
    2. my verbal confirmation of the existence of the agreement during the telephonic application process.

I 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,
Printed Soft

Full Name:

Signature

Date


Supported File Types : PNG, JPG, JPEG, GIF, PDF