applicationform

							Who Referred you to Globex? Globex ID, name,
business name, Globex ID, e-mail address,                                                        Young & Able cc
website address or other?
                                                      CONTACT PERSON’S DETAIL:
                                              Please complete and Fax to : 086 630 6544
Title                    Initials                               Surname
ID Number                                                                 Cell Number
Telephone No. (H)        (          )
Telephone No. (W)        (          )                                     Fax No.          (     )
                                                      PHYSICAL ADDRESS DETAIL:
Complex/Building                                                                               Number
Street Number                                                   Street Name
Suburb                                                       City
Province                                                                                Postal Code
                                                         PAYMENT DETAIL:
                                                       Debit order Bank Detail:
Bank Name
Branch Name                                                   Account Type          Cheque            Savings       Transmission
Bank Code                                              Account Number
Account Holder               (If Business) Business Name
 (If Person) Title                         Initials                     Surname
                              Cash payments can only be accepted if you pay 12 months in advance.

                       Help us to improve our service – Where did you hear of Globex Internet Service?
E.g. Friend, newspaper, current subscriber

Referred by (email address):

                                           Operating system? (Tick the appropriate box)
Win 95                                  Win 98                       Win 2000                            Win XP
Linux                                   Free BSD                     Win 2003                            Win ME
                                               Which E-Mail Program are you using?
Microsoft Outlook                       Outlook Express              Netscape Messenger                  Eudora Light

                             CUSTOMER SATISFACTION GUARANTEED
                                                        Services Required
                                   SERVICE                                                 PRICE (P/ M)              T ICK TO SELECT


                                                       Dialup Connections
56K Dial-up                                                                       R70 p/m
Isdn                                                                              R99 p/m
Isdn Multilink                                                                   R125 p/m
ADSL 512k (3 Gig)                                                                R299 p/m
Fax-2-Mail                                                                          FREE
                                   Free Webmail – Free Spam Filter – Free Virus Filter
                                                  E-Mail Address
Globex E-Mail Address (e.g. yourname@globex.co.za)                                R10 p/m
Domain E-Mail Addresses (e.g. yourname@yourbusiness.co.za)                          FREE

                                             Enter your e-mail address here
                         T HE NAME YOU SPECIFY SHOULD NOT EXCEED 12 CHARACTERS AND NOT LESS THAN 3.
1
2
3
4
5
                                                        Domain Packages

G100 – 2MB Space, 100mb Traffic, Unlimited e-mails                                    R29 p/m
G200 – 5MB Space, 200mb Traffic, Unlimited e-mails                                    R58 p/m
G300 – 10MB Space, 300mb Traffic, Unlimited e-mails                                   R87 p/m
G500 – 15MB Space, 500mb Traffic, Unlimited e-mails                                   R145 p/m
G1000 – 20MB Space, 1 Gig Traffic, Unlimited e-mails                                  R290 p/m
G2000 – 50MB Gig Space, 2 Gig Traffic, Unlimited e-mails                              R580 p/m
                                               All packages include 14% VAT
                                             Domain Name Registration
PLEASE SUPPLY US WITH THE DOMAIN NAME YOU WOULD LIKE US TO REGISTER. WE WILL FIRST CONFIRM AVAILABILITY BEFORE THE FINAL
                        REGISTRATION. T HE ONCE OFF COST FOR THE DOMAIN REGISTRATION IS R 200-00
                                               (co.za / com / net / biz / org / net )
                                       ST                                                     ND
                                      1 OPTION                                               2 OPTION
DOMAIN N AME:

I/We hereby understand and accept the terms and conditions as stated below in terms of this agreement between myself/us and i2i Computers
CC t/a Globex Internet Services, hereafter referred to as “Globex”: I/We also hereby request you to draw against my/our account, with
whichever bank/building society it may be, the amounts required under the above-mentioned contract or any renewal thereof
and I/we authorise my/our bank/building society to DEBIT my/our account with any amounts drawn against it in terms of this
Contract. An Globex reserves the right to change the configuration, product structure, cost or any other components on all
services rendered from time to time. Every notice or other communication required or permitted hereunder shall be sufficientl y
given or transmitted if and when it is send by means of electronic transmission (electronic mail m essage) or displayed on
Globex’s web portal (www.globex.co.za) for the said period. I/We hereby acknowledge that it is my/our responsibility to keep
my/our user name and password a secret and acknowledge that I/we have the ability to upgrade above-mentioned contract
using this user name and password. I/We hereby understand that the services rendered will be subject to Globex's conditions o f
use as amended from time to time. A copy of these conditions is available at any Globex branch or online at:
http://globex.co.za/home/userpolicy.htm. I/We acknowledge that we are bound to a 3-month contract from the date of signing
and understand that this contract will automatically be renewed on a month to month basis. A one calendar month written notice
is required to terminate this contract after the initial period. I/We understand that Globex reserves the right to take ownership of
any domain that is cancelled and not transferred to another ISP. I/We indemnify Globex against any damage, loss, claims or
cost that may result from work being done in connection with the service being rendered and/or removal of the service. Should
I/we fail to pay my/our account I/we shall be liable for any collection, tracing and/or legal fees. I/we hereby confirm that the
mentioned physical address shall by my/our Domicilium citandi et executandi. An administration service fee of R80 will be levied
on all non-payments via DEBIT order. Should I/we fail to pay my/our account, Globex reserve the right to terminate this
agreement without notification. A reconnection fee will be applicable should I/we choose to reactivate this contract, this fee will
be determined by Globex at its own and sole discretion. Interest is payable on all arrear payments at a rate determined by
Globex from time to time.
Authorized Signature:                                                   Date: