(DD) #25 CBC001 – Cibecs Cloud Electronic order and agreement form Step 1 of 4 25% Cibecs Cloud TrialYou are signing up for a free 14 day Cibecs Cloud Trial.Trial sign-up requires payment details to ensure uninterrupted service if you choose to continue with Cibecs Cloud.You will not be charged until after your free trial ends. Thereafter you will be billed monthly.You can cancel your free trial at any time by sending an email to firstname.lastname@example.org.By cancelling your free trail, the provided service will be cancelled and all backed up data will be permanently deleted.Configure your service:Were you referred by a sales consultant or reseller?*YesNoPlease provide the Referral codei.e CBC-R00001Number of Total Users*Number of Total Users*Please enter a value between 10 and 150.Add Storage20GB storage/user (Included)Add Storage*20GB storage/user (Included)50GB storage/server (+R37.50)100GB storage/server (+R75.00)250GB storage/server (+R187.50)500GB storage/server (+R375.00)1TB storage/server (+R768.00)Do you need additional disk space?Monthly Fee Price: R0.00 incl. VAT - Only applicable when trial ends.Monthly Fee Price: R0.00 incl. VAT Your company information:Name* First Last Email* Direct Line*Company Name*VAT NumberAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Cibecs Cloud TrialYou are signing up for a free 14 day Cibecs Cloud Trial.Trial sign-up requires payment details to ensure uninterrupted service if you choose to continue with Cibecs Cloud.You will not be charged until after your free trial ends. Thereafter you will be billed monthly.You can cancel your free trial at any time by sending an email to email@example.com.By cancelling your free trail, the provided service will be cancelled and all backed up data will be permanently deleted.Buy Cibecs CloudEnter your payment details- No commitments, cancel online anytimePayment method:Pay Using?Credit CardBank AccountEFTCredit card details:Credit Card* MasterCardVisa Card Number Month010203040506070809101112 Year20172018201920202021202220232024202520262027202820292030203120322033203420352036 Expiration Date Security Code Cardholder Name Bank account details:Bank*ABSA BANKCAPITEC BANK LIMITEDFIRST NATIONAL BANKFIRSTRAND BANKINVESTEC BANK LIMITEDNEDBANKSTANDARD BANKABSA-ITHALAAFRICAN BANKALBARAKA BANKBANK OF ATHENSBANK WINDHOEK BEPERKBIDVEST BANK LIMITEDCITIBANKFBC FIDELITY BANK LTDGRINDROD BANK LIMITEDHABIB OVERSEAS BANK LIMITEDHBZ BANK LIMITEDHONGKONG & SHANGHAI BANKINGMERCANTILE BANK LIMITEDMTN BANKING(STANDARD BANK)NEDBANK LESOTHO LIMITEDNEDBANK LTD INC BOE BANKNEDBANK NAMIBIANEDBANK SWAZILAND LIMITEDPEOPLE BANK LTD INC PEP BANKPEOPLES BANK LTD INC NBSPERMANENT BANKSA POST BANK (POST OFFICE)SA BANK OF ATHENSSA RESERVESOCIETE GENERAL JHB BRANCHSOUTH AFRICAN POST OFFICESTANDARD BANK SWAZILANDSTANDARD CHARTERED BANK SASTANDARD LESOTHO BANK LTDSTATE BANK OF INDIASWAZILAND DEV AND SAVINGS BANKTHE ROYAL BANK OF SCOTLAND N.VUBANK LTDVBS MUTUAL BANKBranch Code*Account Number*Type of Account*Current (Cheque)SavingsTransmission Agreement:Abbreviated short name as registered with the acquiring bank: CIBECSRefer to our contract reference number (“the Contract Reference Number”):Reference*Contract Amount R0.00 incl. VATTerms of AgreementI/We hereby authorise Datafox (Pty) Ltd to issue and deliver payment instructions to your banker for collection against my/our abovementioned account at my/our abovementioned bank on condition that the sum of such payment instructions will not differ from my/our obligations as agreed to in the Contract Reference. The individual payment instructions so authorised must be issued and delivered on the date when the obligation in terms of the Agreement is due and the amount of each individual payment instruction may not differ as agreed to in terms of the Agreement. I/We agree that the first payment instruction will be issued and delivered on 23/09/2017 and thereafter regularly on the 1st of each month. If however, the date of the payment instruction falls on a non-processing day (weekend or public holiday) I agree that the payment instruction may be debited against my account on the following business day; or subsequent payment instructions will continue to be delivered in terms of this authority until the obligations in terms of the Agreement have been paid or until this authority is canceled by me/us by giving you notice in writing of not less than the interval (as indicated in the previous clause) and sent by prepaid registered post or delivered to your address indicated above. Mandate I/We acknowledge that all payment instructions issued by you shall be treated by my/our abovementioned bank as if the instructions had been issued by me/us personally. Cancellation I/We agree that although this authority and mandate may be canceled by me/us, such cancellation will not cancel the Agreement. I/we also understand that I/we cannot reclaim amounts, which have been withdrawn from my/our account (paid) in terms of this authority and mandate if such amounts were legally owing to you. Assignment I/We acknowledge that this authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party.Signature*Signature verified by BankNameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.