Consumer Application Form

Agent to complete:
New application Change of ownership
Porting of mobile number
Service required Fixed Mobile Convergence
Campaign name
Order no. Account no.
System customer ID.

Supporting documentation (new customer) Supporting documentation Sections to complete

• Proof of identification: Copy of SA ID or (existing fixed/mobile customer) New application: 1, 2, 3, 5A or 5B, 6
passport (including work permit) • Proof of identification: Copy of SA ID Change of ownership: 1, 2, 3, 4, 5A, 5B, 6
• Copy of your most recent payslip and or passport (including work permit) Porting: 1, 2, 3, 5A, 5B, 6
three months’ bank statements
• Copy of proof of residence (utility bill not
older than three months)
• For porting purposes, account number at
donor/existing service provider required

1. Customer details
Are you an existing customer? Yes No If yes, what is your existing number?

Title Surname First names

SA Citizen Yes No Identity/Passport no. Passport expiry date

Gender M F Date of birth
Contact details Home no. Office no. Mobile no.
Email address

Physical address Unit/Stand no/Street

Suburb City Postal code

Postal address Same as above PO Box/P Bag Suburb/City Postal code

How do you like to receive your invoice? Email (Compulsory for all broadband services) Post (Additional charges may apply)

2. Employment details
Name of your employer Occupation
Employer’s address

Suburb City Postal code

Employer’s contact no. Period employed Years Months

Gross income p/m Net income p/m Total expenses p/m

Household income p/m

3. Payment detail (debit order compulsory)

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

Bank Branch name Branch code

Account holder name Account no.

Type of account Cheque Transmission Savings

Debit order maximum amount Debit dates 15th 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

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 4. Change of ownership (existing owner’s details)
Number(s) to be changed & Change of ownership date
Initials and surname ID no.

Contact details Home no. (new) Office no. Mobile no.

Final invoice Email Email address
Post
Postal address
Suburb City Postal code

Signature (existing owner) Signature (new owner)

5. Your order/services
A. Fixed-line and converged products

How many lines do you require? When do you require your telephone service?

Do you want to use your existing line? Yes No If yes, what is the telephone number?

Service provider of existing line

Do you want your landline details in the phone book? Yes No

Fixed stand-alone

Calling plan (voice service)

(Cancellation within six months may be subject to
Telkom Broadband service Yes No Contract period 24 Months Monthly payment of a reasonable setup cancellation fee)

Technology/Speed Lite* Fast Faster Faster + Fastest Elite Elite + Fibre 100*
* Lite is not available on Fibre. Fibre 100 is not availalble on DSL.
(Factors that can affect your speed may include: distance from the exchange to your home; peak internet usage times; the number of people sharing your broadband connection within your home; or you may have
reached your Telkom Internet SoftCap.)

Internet plan

Self-install Yes No (Installation charges applicable for month-to-month contracts)

Device add-on

VAS add-on

Family Circle service Yes No Telkom mobile no. 1 Telkom mobile no. 2

Telkom mobile no. 3 Telkom mobile no. 4

Converged bundles
Bundle description Technology Contract period

B. Mobile products

Spend limit (Over and above monthly subscription; subject to credit management approval) R150 R300 R1000 No limit

Package/deal ID Device make/model Itemised billing Additional value-added services Contract period

Yes No

Yes No

Yes No

Insurance Yes No Band 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 to 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 to 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

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C. Mobile numbers to be ported to Telkom mobile (mobile and convergence)

Account Account type DSP* Account no. Account Mobile number RICA person name RICA person Requested
classification at DSP* at DSP* name (person RICA’d ID/Company port date
at DSP* prepaid, consumer (per invoice) at DSP* at DSP*) reg. no. YYYY/MM/DD
postpaid or hybrid or business (per invoice)

*(DSP = Donor/Existing Service Provider)

I, the undersigned, hereby confirm that I have been informed of the following and agree to these statements:

1. I am porting to Telkom mobile.

2. I acknowledge that, in the event of donor service provider rejection, my service will be activated with a 081/061 Telkom mobile number.

3. I acknowledge and accept that call credits/unused values from the donor service provider are forfeited.

4. I am responsible and liable for outstanding fees owing to the donor service provider.

5. I am responsible for all reasonable cancellations fees incurred when a cancellation request is received during the application process.

6. Products and services offered at the donor service provider might not necessarily be available at Telkom mobile.

7. I have read, understood and hereby agree to the terms and conditions as set out in the application form.

Signature Date

6. Agreement
I (and/or the Applicant), 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:
a) my agreement via tick box and submission of the online application form; or
b) my verbal confirmation of the existence of the agreement during the telephonic application process.
I (and/or the Applicant) 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, or

Email address

Full name Signature Date

7. For office use only

Dealer name

Full name Signature Date

RICA information (required for mobile products): RICA by sales agent RICA on delivery

B2C delivery address: Customer address Employee address

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