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    Payment Method: (required)
    Debit OrderOnline Card Payment

    Payments are processed on the FIRST BUSINESS DAY of every month.

    For RICA and/or vetting purposes the following documents are required.

    Business Account
    - Company Registration - ALL PAGES (if applicable)
    - Company VAT Certificate (if applicable)
    - Company Letterhead
    - Company Proof of address - not older than 3 months
    - Company Bank account confirmation letter - not older than 3 months
    - Director/Owner Certified copy of ID
    - Director/Owner Proof of Address - not older than 3 months

    Private Account
    - Account holder Certified copy of ID
    - Account holder Proof of Address - not older than 3 months
    - Address must match with physical address provided during sign-up (otherwise contact me so we can change this address to match your document.)
    This does not have to be the same address where the internet service is being installed/used, however, in some cases a proof of address for the service location is also required.

    Number Porting (if applicable)
    - Latest bill from current service provider
    - Signed porting authorisation form

    Your application can only be processed once this form is submitted with all the applicable documents attached or sent via e-mail to

    I/We hereby authorize NAXLAV (PTY) LTD to draw against the above mentioned bank account with payments due as indicated on my/our monthly invoice, on the nominated day of each and every month commencing on the due date of the first recurring invoice. NAXLAV (PTY) LTD will not be held liable for any inconveniences, costs or losses incurred due to the supply of incorrect account or card details.

    1. I/We certify that these details are true and correct and agree to advise NAXLAV (PTY) LTD of any changes to my billing details as they occur.
    2. I/We understand that in the event that a debit order is rejected by my/our bank, all related bank rejection fees, NAXLAV (PTY) LTD administration fees, plus the full
    outstanding amount will immediately become payable. It is the responsibility of the account holder to ensure that payment is made in full to avoid credit control procedures taking effect which may lead to the suspension or termination of services. I/We therefore undertake to ensure that adequate funds are available in my/our bank account to cover the monthly amounts due. I/we understand dat NAXLAV will automatically cancel the debit order authorization should the debit order be rejected by the bank three consecutive months in a row.
    3. This authority may be cancelled by me/us by giving NAXLAV (PTY) LTD 30 (thirty) days notice in writing. I/We understand that I/we shall not be entitled to any refund of
    amounts which NAXLAV (PTY) LTD have withdrawn while this authority was in force if such amounts were legally owing to NAXLAV (PTY) LTD.

    By signing below and/or submitting this form you accept the above and our full Terms and Conditions and acknowledge that NAXLAV (PTY) LTD and/or its representatives cannot be held liable for any data loss, physical loss, theft, damage, unforeseen damage, factors beyond our control and/or claim of any kind directly or indirectly.

    Applicant Signature