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LTE-A ORDER FORM

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Dear applicant. The information you are about to supply to bitCONNECT will serve to aid us in processing your application. bitCONNECT will not share, sell or otherwise distribute this information. Our website is encrypted to protect you from prying eyes. Please ensure that you see the green lock icon in your browser address bar before you submit any information.
Referral Code
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
City
Post Code
GPS Coordinates

Packages

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
Monthly Package Price
MonthlyR0.00

Hardware

LTE Router
Choose your router
Payment Terms
You may choose to pay your router over a specified period of time. Please choose below the payment terms you prefer
-
+
WiFi Router
Once-offR0.00
WiFi Router
MonthlyR0.00
Dish
Once-offR0.00

Totals

Total Monthly Cost
The total amount that will be payable monthly
MonthlyR0.00
Total Once-off Cost
The total amount payable once installation is complete
Once OffR0.00
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
Branch Code
DEBIT ORDER AGREEMENT
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}.



MANDATE



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.



CANCELLATION



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may be cancelled by me/us, but I/We understand that I shall not be entitled to any refund of amounts, which you have withdrawn whilst this Authority was in force if such amounts were legally owing to you.



ASSIGNMENT



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?
TERMS & CONDITIONS
Please read and agree to these terms and conditions
Agree to T&C
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