Order Form
Lead Form
Name
*
Surname
*
Contact Number
*
Alternative Number
Email
*
ID Number
*
Address
*
Address
Address
Address
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
Have you checked if you have coverage
*
Yes
No
Preferred method of contact
*
SMS
Email
WhatsApp
Phone Call
Preferred time for contact
*
Chosen package
ISP
*
Line Speed
*
15/15
30/30
50/50
100/100
200/200
1000/500
Price
*
Sales Agent Name
*
Comment
*
I hereby grant Zoom Fibre (PTY) LTD permission to distribute any documentation provided by me to my chosen Service Provider. I acknowledge that I have not been requested by any Zoom Fibre Agent / Contractor / Employee to make an upfront payment for the service I'm ordering today. I acknowledge that I have not made any payment (cash/eft/other) to any Zoom Fibre Agent / Contractor / Employee for the service I am ordering today
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