TelkomSupporting documentation• Proof of identification (certified copy of SA ID or passport)• Copy of your most recent payslip and 3 months' bank statements• Copy of proof of residence (utility bill not older than 3 months)» For porting purposes, account number at donor/existing service provider required

Consumer Application Form

Agent to complete:

New application | j Contract renewal j I Transfer [_] Discontinue

Change of ownership Hj Date required L

Order No. T ! Account No.

Porting of mobile number j_ j Value-added services

Service required Fixed j ' Mobile j Convergence j i

ORIGINAL COPY

1. Customer details

Are you an existing customer? Yes f No j^J If yes, what is your existing telephone number?

First NamesTitle Surname

Passport Expiry Date MSA Citizen Yes 0 No 0 Identity/Passport No.

Gender M 0 F0 Dateof Birth 00000000

Marital Status Married [ | Single j j Divorced [ j Widowed [̂ j How are you married?* COP 0 ANC j [ ANC with accrual | [ Customary

How do you like to receive your invoice? Post [̂ Email! Email Address [_

n Off icerYour contact numbers Home Mobile Number

Physical Address Unit/Stand/Street [_

Postal Address Same as above 0 po Box/P Bag }

Friend or Relative Name and Surname

City Province

Contact Number

Select your preferred method of communication Email |_ j SMS j_ ] Telephone \_

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

Postal Code

2. Employment details

Name of your employer j

Employer's Address

Suburb I

Occupation

City

CityPostal Address PO Box/P Bag

Period Employed J Years [ ^] Months Employer's Contact No.

Gross income per month | R

Province

Province

Postal Code

Postal Code

Net income per month |R Total monthly expenses R Household income IR

3. Banking details (debit order compulsory)

Should you not have sufficient funds in your account on the required due date, Telkom will make use of NAEDO to collect the arrears amount.

These collections will be at your cost.

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

Branch NameBank Branch Code

Account Holder Name Account No.

Type of Account Cheque \_ | Transmission [_ ] Savings [_

Debit Dates 5th 0 10th0 15th0 20th Q 25th Q] Last day of the month | |Debit order maximum amount

Full Name Signature Date

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4. Change of ownership / Discontinuing your service

Change of ownership j~_ Discontinuing your service Q

Please provide your telephone numbers) to be changed to new owner [_ ~| & j^

Date for Change of Ownership 00! '•_ _1J0000 Final Invoice via Post0 Email 0 Email Address Q

Initials and Surname I i ID No. f

Reason for Discontinuance |

Physical Address Unit/Stand/Street |

Suburb 1

Postal Address Same as above ( j PO Box/P Bag |_

Contact numbers Home[

Signature (existing)

Date of Discontinuance 0 0 0 0 0 0 0 [1

Postal Code

Postal Code 0000

Q0000 Mobile Number 00[~~| 0 00j | |

Signature (new owner)

5. Your order/services

A. Fixed Line and Converged Products

How many ilnes do you require?

Do you want to use your existing line? Yes

When do you require your telephone service? [J

No Ifyes, what is the telephone number? |

Service provider of existing line (_

Fixed Stand Alone

Telkom Voice Line

Telkom Fixed Line look-alike

Tpikrim n^l j inp

DSI 1 inp =;r>pprl rpqnirpri

Splf-instnl!

rnllinrj Plnn

Internet

Converged Bundles

Fixed

LIE

3G

B. Mobile

Contract Period

Monthly

Monthly

Monthly

Frist

YPS

Monthly

Monthly

Contract Period

Monthly

Monthly

Monthly

0

i 1

0

120

120

120

Faster j

120

12 0

2*0

360

2,0

'

2* O

2, 0

2, 0

Fastest 0 Elite 0 Elite + [

2. | | Caliim

2, L

I '-••"

j '.; • - • . • ' • ;;i..:icd

36 | E ind

Package/Deal ID* Device Make/Model* Itemised Billing*

Yes0 No0

Yes0 No0

Yes0 No0

Yes0 No0

Yes0 No0

VAST* VAS2 Spend Limit* Contract Period

Total/minimum monthly cost*

"If no quote is done, these fields are all mandatory. Subject to credit management approval.

"VAS = Value Added Services

Authorised Signature Date

VI.0815 Page 2

C. Mobile, numbers to be ported to Telkom Mobile (Mobile and Convergence)

Account Classificationat DSP* Prepaid,

Postpaid or Hybrid

Account Type at DSP*Consumer or Business

DSP* Account no.at DSP* (Per

Invoice)

Account name atDSP* (Per Invoice)

Mobile Number RICA Person Name(Person RICA'd

at DSP*)

RICA PersonID/Company

Reg. No.

RequestedPort Date

YYYY/MM/DD

'(DSP = Donor/Existing Service Provider)

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

• I am porting to Telkom Mobile.

• I acknowledge that, in the event of Donor Service Provider rejection, my service will be activated with an 081 /061 Telkom Mobile MSISDN number.

• I acknowledge and accept that call credits/unused values from the Donor Service Provider are forfeited.

• I am responsible and liable for outstanding fees owing to the Donor Service Provider.

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

• Products and services offered at the Donor Service Provider might not necessarily be available at Tefkom Mobile.

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

Authorised Signature Date

6. Agreement

I 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 anydamages suffered by it, should it at any stage appear that I'm not so authorised.

2) The information supplied herein with regard to me and the Applicant 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 and/or the Applicant as if I have signed a physicalapplication form, upon:a) my agreement via tick box and submission of the online application form; orb) 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:

a) Telkom's Standard Terms and Conditions for the Provision of Electronic Communication Services and Products (fixed-line services and products),available at http://www.telkom.co.za/general/termsandconditions/index.html; and/or

b) Telkom Mobile Subscriber Terms and Conditions (mobile services and products) available at www.telkommobile.co.za/terms/; and

c) 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 telephonicallyduring a telephonic application process. I declare myself familiar with and bound to the content of said terms and conditions. All these terms andconditions are available online and will be made available to me in printed version or may be emailed to me, if I so request it.

Copy of terms and conditions Yes !_

Email soft copy to (~

Full Name

Print hard copy Yes [̂ ] No [

Signature Date

7. For office use only

Dealer Name

Campaign Name

Signature as Witness

Dealer Code

Sales No. ] Telkom Sales Representative

Date

Yes 0 No 0 Credit Limit f

RICA Information (required for mobile products):

Customer Representative as RICA Agent |_ RICA by Sales Agent RICA on Delivery Q

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