30 Day Free Trail      Contact Name:                                             First Name                                                                      Last Name   Tel                                                                                    Cell   Email                                                                                 ID number:   Company Details:                                             Company Name                                                                                VAT Number (if registered)  MAIN OFFICE NUMBER: This is the landline number to which we should divert the new Paytel number too. i.e. Your main business line "hunting line",  switchboard or enquiries line. The line which you will answer to earn income. NB!(no cell phone numbers allowed, strictly only land line numbers)               To which bank account should we pay your commission and deduct the setup fee:    Bank Details:                              Pay by:          Savings        Cheque   Transmission      Credit Card      Bank                                                                      Branch Name                                                   Branch Code      Account holders Name                                                        Account number Credit Card only:     Card no:                                                                                                  Expiry date:                           Card Type:                                                      CVV no (Last 3 digits on back of card):    Please tick ONLY ONE! Unless I  cancel the 30 day trial before it expires, I hereby grant Paytel Networks authority to debit my account with the  R360.00  once off setup  fee  30 days from signature hereof.  R360  (30 day trial)  (Special offer) I prefer to receive an instant activation discount of R65  and here with forgo the 30 day trial application and instead opt for a instant activation.  I authorize Paytel do deduct the discounted instant activation fee of R 295 of my account after signature hereof.  R 295 (30 day trial not applicable) Terms and Conditions I hereby acknowledge that I have read and understood all of the conduct rules terms of use policies as outlined in the terms and conditions on the Paytel Website (www.paytel.co.za) and agree and accept they form part of this agreement.                                                    Signed at                                               Date                                Applicants Signature: Please fax this application to 086 696 4362                           Referral ID:     9719