Vox Telecom Dealer Application Form

Please complete the following form:

APPLICATION DETAILS
  * Required fields
Type:   Business Individual  
Date:    
 

Personal Information

       
First Name:   *
Last Name:   *
Initials:   *
ID number:   *
       
Physical Address:      
Street name and number   (number) *
Unit / Flat / Office   *
Suburb:   *
City:   *
Province:   *
Post code:   *
       
Postal Address:      
Postal Address:    
Suburb:    
City:    
Province:    
Post code:    
       
Email:   *
Tel no. (work): *
Tel no. (home): *
Cell   *
Fax    
Gender:   Male Female  
Are you a Vox Telecom customer?   Yes No  
Have you been a dealer before?   Yes No  
Dealer number:    
       

COMPANY INFORMATION (only applicable to registered business entities)
Type of company:    
Name of company:    
Industry:    
Number of Employees:    
Tax number:    
Date established:    
Physical Address:    
Postal Address:    
Post code:    
Province:    
Email:    
Tel no:  
Are you a Vox Telecom customer?   Yes No  
Have you been a dealer before?   Yes No  
Date of dealer expiry:    
       

PAYMENT INFORMATION
       
PLEASE NOTE:   There are three different payments that will occur. Please select your preferential account for each payment type. You must complete both bank account and credit card details in order for this application to be accepted.  
First payment:   Credit card Bank Account  
Monthly debit order:   Credit card Bank Account  
Receive commissions:   Credit card Bank Account  
       

Banking Details

       
Account holder:   *
Name of bank:   *
Account type:   *
Branch name:   *
Branch code:   *
Account number:   *
       

CREDIT CARD DETAILS
Cardholder name:   *
CVV no. (on back of card):   *
Expiry date:   *
Type:    
Credit card number:   *
       

Terms and Conditions

I hereby acknowledge that I have read and understood all of the conduct rules and policies as outlined in the attached terms and conditions and agree and accept that they form part of this agreement.
   
    Click here to read the terms and conditions