SUBSCRIBER SERVICE CONTRACT

							                                                                                                                                  www.iburst.co.za
                                                                                                            WBS Service Provider Company (Pty)Ltd
                                                                                                                               66 Park Lane Sandton
                                                                                                                        P O Box 651921 Benmore 2010
                                                                                                           Tel: +27 11 676 6000 Fax: +27 11 676 6005
 SUBSCRIBER SERVICE CONTRACT                                                                            Reg No. 2004/029951/07   VAT Reg No. 4100219643

 SUBSCRIBER DETAILS
 Subscriber | Individual                Business            Existing Client           Existing Client No.

 Title      Mr          Mrs           Ms            Other                                      Business Name

  First Name/s

  Surname                                                                                      Business Reg. No.

         RSA ID No.

         Passport No.
                                                                                                                        Same as Physical
  Physical Address                                                                   Postal Address




  Home Telephone Number                                                              Cell Number


  Work Telephone Number                                                              Fax Number


  E-mail Address


 PACKAGE INFORMATION
  iBurst Modem |             Laptop Modem (UT-C)                    Desktop Modem (UT-D)                USB Modem (UT-U)
  For Official Use Only
  Modem ID (UTID) Number                                                             Serial Number


 Modem Purchase Price R

  iBurst Package |            Monthly Charge            Quantity       User Name & Password (Do NOT use first or last name)
                                                                      User Name 1st choice:
         iBurst i-Go Lite     R
         iBurst i-Go          R                                       User name 2nd choice:

         iBurst G1            R                                       Password:
         iBurst G3            R                                       Password Hint Question:
         iBurst G6            R
         iBurst G9            R                                       Password Hint Answer:

  Contract Period |           Month-to-month                 24 Months
  Order Details |                                                               Value Added Services |                 Quantity               Price Excl. V.A.T.
  Description                     Quantity            Price Excl. V.A.T.         Description
 Connection fee
 Activation fee
 Delivery fee (if applicable)
 Deposit (if applicable,
 refundable after 12 months)                                                                                               Sub Total
                                     Sub Total                                                                                  V.A.T.
                                          V.A.T.                                                                    Total Incl. V.A.T.
                              Total Incl. V.A.T.

  Delivery Method |                 Collection            Del. Address:
                                       Courier
                              Sales to deliver
 BANK DETAILS AND DEBIT AUTHORISATION
Preferred date for Monthly Debit    Account Type |                                  Cheque            Current           Savings               Transmission
Bank Name                                                                            Branch Name

Account Number                                                                       Branch Code


I/We,                                                                     , the undersigned, confirm the accuracy of the information contained in this document and
warrant that I am duly authorised to sign on behalf of the subscriber. I acknowledge that I have read, understand and agree to be bound by the terms and conditions
upon signature hereof. I hereby instruct WBS SP to debit my bank account with the amounts which are due and payable in terms of this agreement. I hereby consent to
WBS SP performing a Credit Clearance Verification.

Print Name                                                                                     Date
Authorised Signatory/ies