Business Hosting Plan

Name (Debtor)
Address
City
State
Code
Country
Contact
E-mail

R200.00 per month

Unlimited bandwidth

350MB disk space

20 POP3 mailboxes

50 MB per mailbox

Applicants Details

Domain Name
http://

Online Bank Debit Order Instruction / Credit Card Authority

Signatory Name

Date

The details of my bank account are as follows: (Please choose 1 method of payment – Bank Account or Credit Card)

Card Type
Name on Card
Card Number
Expiry / Payment Details
Bank
Branch
Branch No
Account No
Type of A/C A/C Name Card Holder
CVV Number (3 Last Digits)

I/we hereby request and authorize you to draw against my/our account with the abovementioned bank (or any other
bank or branch to which I/we may transfer my/our account) the sum of _________________________(state amount in words) or any variable amount pertaining to this agreement, on the first working day of each month. This being the amount necessary for the settlement of the monthly due to you in respect of our purchases/contract/agreement dated

All such withdrawals from my/our account by you shall be treated as though they had been signed by me/us personally.

NB: PLEASE PRINT AND SIGN THIS FORM OR DOWNLOAD AND COMPLETE THE ORIGINAL FORM AND FAX IT TOGETHER WITH YOUR PROOF OF PAYMENT FOR THE PRO RATA MONTHLY FEES OF R200.00 TO 0866990543. ONCE WE RECEIVED THE PROOF OF PAYMENT WILL WE ACTIVATE YOUR ACCOUNT AND SEND YOU YOUR LOGIN AND PASSWORD VIA EMAIL

Signature of Applicant

Kings Word Network

CC 2009/027677/23

8 Beveland Street, Highbury Kuilsriver 7580