Cybervale Internet Service

Membership Application Form

ADSL Account Information

FULL NAME (BLOCK LETTERS ONLY FOR ALL AREAS )

Date of Birth: dd/mm/yy HOME TEL No: MOBILE No:

HOME ADDRESS:

ADSL TEL No: OTHER EMAIL ADDRESS: ID TYPE & NO:

Class of ADSL Service Required

Residential 1 year contract Month to Month

256 Kbps/128 Kbps (US $29.95) per mth -

512 Kbps/128 Kbps (US $34.95) per mth -

1024 Kbps/256 Kbps (US $49.95) per mth -

Business 2 years contract

1024 Kbps/256 Kbps Not available (US $325.00) per mth

1544 Kbps/384 Kbps (US $149.00) per mth (US $500.00) per mth

2048 Kbps/512 Kbps (US $249.00) per mth Not available

Kindly note that a setup charge of US $20 for Residential and US $29.99 for Business should be applied for any service required.

I, the undersigned, certify that I have seen, read and understood the “Terms and Conditions of Service”.

I also certify that the information provided in this application is true.

Applicant’s Signature: ______________________ Date: _____________________

(Min 2, Max.10) (Min. 5, Max.10)

User Name: ______________________ Password: __________________________