za Customer Registration Request Form | AW

Phone

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Next Steps: Install the User Registration Add-On

This form requires the Gravity Forms User Registration Add-On. Important: Delete this tip before you publish the form.

Name(Required)

First Last

Company Name

Are you VAT registered?(Required)

VAT Number(Required)

Physical Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Is company Address same as physical address?(Required)

Company Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Email(Required)

Enter Email Confirm Email

Cell Phone Number(Required)

Ability to receive SMS is required.

Package(Required)

Domian Name you would like(Required)

Please double-check the spelling, as once the domain is registered, it cannot be changed, and a new domain must be registered.

Select extensions for domian(Required)

Just a heads-up on the pricing for the .co.za domain: You’ll have your standard monthly package (e.g., R80/month), plus a yearly renewal fee of R150 + VAT for the domain itself, which falls due every March 31st.

Just a heads-up on the pricing: because this isn't a .co.za domain, the yearly renewal is R350 + VAT. So, if your package is R70/month, you’ll just have that extra domain fee once a year every 31st of March.

Details of payment via debit order

Bank account name:(Required)

Bank account number:(Required)

Select Bank(Required)

Account Type(Required)

ID Number(Required)

Upload ID Copy(Required)

Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB.