Online Application Form
 
Connectivity Solutions
 
Personal Information
Name & Surname: *
Company:
VAT number (if relevant):
Company Contact:
ID / Company Registration Number: *
Email Address: *
Telephone Number: *
Fax Number:
Mobile Number:
Postal Address: *
 
Service Requirements & Cost
Please indicate your choice of connectivity solution by selecting from the list below *
  Monthly Cost Annual Cost
Analogue Dialup 56k    R69    R759
ISDN Dialup 64k R149 R1639
ISDN Dialup 128k R249 R2739
ADSL Broadband 512k (Capped | 2Gig) R189 R2079
ADSL Broadband 512k (Capped | 3Gig) R259 R2849
ADSL Broadband 512k (Capped | 5Gig) R379 R4169
ADSL Broadband 512k (Capped | 7Gig) R489 R5379
ADSL Broadband 512k (Capped | 10Gig) R689 R7689
Business ADSL Broadband 512k (Fixed IP | Uncapped) R1500 once off + R1350 per month
   POA

Required Email Addresses
All connectivity solutions include one email address within the domain allafrica.net.  Please provide us with 3 possible choices for your email address, ranked by importance.
 
Address Choice 1:
     		Address Choice 2:
     		Address Choice 3:
    


Important Notice *  All prices indicated are exclusive of VAT
 
Payment Options & Direct Deposit Details
Payment Options * Direct Deposit Details
Please choose your preferred payment method
Direct Deposit
Monthly Debit Order
Credit Card
A representative will contact you regarding your account details.
Account Holder: Popular Demand Technologies
Account Number: 6202 164 5934
Bank: First National Bank
Branch: The Fountains
Branch Code: 25-79-55
All Deposit Slips to be faxed to 086 686 2622 or sent via email to accounts@populardemand.co.za.
Please include the Invoice Number as reference on the deposit slip/ electronic transfer. We can not be held responsible if the payment cannot be traced.
 

Your Banking Details
Bank Name:    Branch:
Branch Code:    Account Holder:
Account Number:    Account Type:

Credit Card Payments

You will be provided with an invoice number and a secure link for credit card payments,
 as soon as your application has been processed.
 
Confirmation and Submission of Application

By submitting, I agree to the terms & conditions and confirm that all of the information provided in this form is true and correct.

I agree: