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Referral Code
Application type
Is this application for a person or a business?
Company Name
Company Registration Number
VAT Number
First Name
Last Name
ID Number
Primary Phone Number
Secondary Phone Number
Email Address
Address Line 1
Address Line 2
Post Code
GPS Coordinates


Choose Your Package
  • - select a option -
  • Rain 25GB R299
  • Rain 55GB R549
  • Rain 85GB R799
  • Rain 120GB R999
  • Rain 220GB R1349
  • Rain 330GB R1599
  • Cell C 50GB R349
  • Cell C 100GB R530
  • Cell C 200GB R850


LTE Router
Please choose whether you need a SIM only or an LTE router


Total Monthly Cost
The total amount that will be payable monthly
Total Once-off Cost
The total amount payable once installation is complete
Once OffR0.00
Payment Terms
You may choose to pay your router over a specified period of time. Please choose below the payment terms you prefer
Account Name
Account Number
Debit Order Start Date
Debit Date
Bank Name
  • - select a bank -
  • ABSA
  • Capitec
  • FNB
  • Nedbank
  • Standard Bank
Account Type
  • - select account type -
  • Current/Cheque
  • Savings
  • Transmission
  • Credit Card
Branch Code
Debit order is mandatory with a 24 month agreement

I/We hereby authorize La Rochelle IT Solutions T/A Bronberg Connect (the internet service provider) to draw against my bank account with the abovementioned bank (or any bank or branch to which I may transfer my account) the sum of {total_monthly} on the {debitdate} of each and every month, commencing on the {debitstartdate}.


All such withdrawals from my bank account by you shall be treated by the above-mentioned Bank as though they had been signed by me personally.


I/We agree that this authority may be cancelled by me/us, but I/We understand that I shall not be entitled to any refund of amounts, which you have withdrawn whilst this Authority was in force if such amounts were legally owing to you.


I/We acknowledge that this Authority may be ceded or assigned to a third party if the Agreement is also ceded to that third party, but in the absence of such assignment of the Internet Service Agreement, this Authority cannot be assigned to any third party.

Do you agree to this debit order?
Please read and agree to these terms and conditions
Agree to T&C
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How did you hear about us?
Please let us know where you have come to hear about us.
  • - select a option -
  • Facebook advert
  • Printed advert
  • Word of mouth
  • Google search
  • Other
Please verify your ID number