Airtime Registration Form
Please print form, complete the details and fax to: 0860-083-083

PERSONAL DETAILS

First Name: Surname:
Title: ID Number:
Cellular No: * *(This will be the cell number that requests and receives the recharge PINS.)
Email Address

Postal address: Work Tel: (incl area code)
Home Tel: (incl area code)
City/Town: Fax No:
Postal Code

Please provide us with a personal question and answer that will be used to identify you if you call our team:
Personal question: ( e.g Mother's maiden Name) 
Required answer to question:   
Referred By: NAME

Frank Mccoy               

Referred By: CELL NUMBER

0848701589

I hereby agree to be personally responsible for all charges payable to the Globe Mobile (Pty) Ltd or its duly authorised agent(s), from time to time, in respect of the processing of any SMS Top-up requests originating from the abovementioned registered cellphone number and any other use of the SMS Airtime Top-up Service by myself or anybody acting on my behalf. I further confirm that I have read and understood the Top-up Service Terms and Conditions that apply to the use of the Top-up Service. I warrant that the information supplied in this Registration Form is true and correct and authorise Globe Mobile (Pty) Ltd or it's duly authorised agent(s) to deduct from any and all amounts paid by me to my Airtime Dealer or its duly authorised agent(s) the amounts of any charges payable in respect of the use of the Top-up Service by myself or anybody acting on my behalf.
Full Names and Surname _______________________________________________________________________

Signature:                       ___________________________________________ Date: _______________________
PAYMENT DETAILS Amount Vat Total
Registration fee R87.72 R12.28 R100.00
Voucher Credit (Minimum to start) R200.00 Nil R200.00
Voucher Credit (optional additional credit in multiples of R100.00)   Nil  
 

TOTAL DUE                             

 

Please deposit the above amount into:
Globe Mobile, ABSA Bank, Branch Code 537-155, Account Number 4056032855.
Please use your Cell Number as a reference on your deposit slip, to ensure that we can identify your deposit.

FAX: 0860 083 083

Home Page

Your Prepaid agency will be set up when this page is faxed back to us. Please ensure that your agency is set up before referring your friends. (You will receive email or SMS confirmation that it is set up)