Chomza Signup Form
Special Pricing Sign up form
Sign in to Google to save your progress. Learn more
Email *
Title: (Mr/Mrs/Ms/Dr/Prof) *
Referred by: (Name of person, Internet, Social Media, Pamphlet etc)
Internet Package you are signing up for (tick) *
Payment method: Select one below; We advise clients to sign a debit order for payments *
Account Holder Name:
Bank: (eg FNB, ABSA, NEDBANK etc)
Account No.:
Branch No:
Type of Account: (select one)
Clear selection
Date of Debit; (select one). 
**If a debit order date falls on a public holiday or weekend the debit order will run the next business day**.
Clear selection
All equipment installed (excluding extras) belongs to Chomza Technologies, this allows for free equipment changes or upgrades to be done when the need comes or when it gets damaged by unforseen natural events. The installation includes 1 x outdoor unit and 1x indoor Wifi unit with a limited WiFi range of about 10m, any extras are for the client cost and may be quoted at time of installation *
**A once off Installation fee of R1999 is applicable with all installations. *
Would you like extra an Lightning and Surge Protection system installed? Cost is R1299 once off. In the event you do not have any surge protection any replacements done for damaged equipment will be at your own cost. *
Terms and conditions: Chomza Technologies is a provider of Internet and IT related services and products. Chomza Technologies does not support Spamming or any form of network abuse and enforces  policies in line with the upstream provider. Chomza Technologies does not allow illegal use of its services, the subscriber herein must conform to laws governing transmission and communications law of South Africa                                                                                                           Sending unsolicited mail messages, including, without limitation, Make-Money-Fast (MMF) schemes, chain letters, commercial advertising and informational announcements, is explicitly prohibited. A user shall not use another site's mail server to relay mail without the express permission of the site.All cancellations must be done in form of email to No refunds are processed on cancellation. Cancellations must be done on a 1 calendar month notice. If on a 24 Months contract, all cancellations carry a penalty equal too installation fee (Between R1999-R3500) which is payable immediately. All data will be forfeited at the point of cancellation. All equipment belongs to Chomza Technologies. Our Support Dept working hours;Monday to Friday - 08:00am till 22:00pm. Saturday and Sunday - 08:00am till 12:00pm. Tel: 0878039156. Cell and WhatsApp: 0837467434. A call out fee of R350 is payable on all call outs to fix home network which are as a result of the users' doing. Payments for all services are due on the last day of each month, all services are prepaid ie. payment for the month of March should be in by the last day February. All payments must be made by transfer, cash deposit or debit order or Credit Card . Bank account; Chomza Technologies (PTY) Ltd , FNB Cheque 62802017609, Branch 250655 Mafikeng. Please use your Surname or Invoice number as Reference. Any outstanding payments will result in services being cut by the 1st of the following month *
A copy of your responses will be emailed to the address you provided.
Clear form
Never submit passwords through Google Forms.
This form was created inside of GrayTech Systems. Report Abuse