SMART CARD

SERIAL No.
STB No.

Acc. No.

MultiChoice Africa Limited

Registration Number 43308 C1/GBL

SUBSCRIBER DETAILS

Mr./Mrs./Ms. Other Initials Fax No.

Surname E-Mail

First Names

Physical Address

Identity
No.
Passport City
No.
Tel. No.
Home Country

Tel. No.
Work Postal Address

Tel. No.
Mobile

AGENT DETAILS
Agents/Installer
Name: Agent Stamp

Tel. No.

Fax No.

Mobile No.

E-Mail

PAYMENT METHOD: PRODUCT DETAILS: RECEIPT DETAILS:

Direct Debit Cheque Cash Bank Draft
DStv
Services IS 7 IS 1O
Bank: Branch Code: RECEIPT No.
Branch Name: W4 / Sesat CURRENCY
Account No.:
Product
Type of Account: Savings Cheque Trans- AMOUNT PAID
mission PVR XtraView

VISA Master Other

Card Dual View

Card No. Subscription Period Months

Agent’s Signature

Expiry Date CVV

No.

SUBSCRIBER ACCEPTANCE
“The Subscriber:
Signed At:
confirms the accuracy of the above mentioned personal information,
acknowledges that he/she has read and understands the Terms and Conditions to this application,
RF56650(v)

upon acceptance of the application by MultiChoice Africa Limited, undertakes to be bound thereby, and Date:
confirms receipt of the smart card in good working order”.
Your Subscriber Application Form must be read together with the Multichoice Digital Satellite Terms and
Lithotech SJ (011) 474-1828

Conditions (Sub-Saharan Africa), and the current version of the User Manual applicable to your decoder, both
of which will be made available upon request and/or are accessible on MultiChoice’s website.
Would you like a copy of the terms and conditions? Yes No Subscriber's Signature:

For MultiChoice use only: Subscriber No. User ID: Date Captured: