:: COMPUTER SUPPORT SPECIALISTS (CSS) ::

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SECTION A:

GENERAL DETAILS

REGISTERED COMPANY NAME:

TRADING AS:

REGISTRATION NUMBER:

VAT NUMBER:

POSTAL ADDRESS:

Code:

STREET ADDRESS:

Code:

TELEPHONE NUMBER 1:

TELEPHONE NUMBER 2:

FAX NUMBER:

COMPANY E-MAIL ADDRESS:

SECTION B:

CONTACT PERSON

NAME:

JOB TITLE:

CELL NUMBER:

TELEPHONE NUMBER:

FAX NUMBER:

E-MAIL ADDRESS:

SECTION C:

ACCOUNTS DEPARTMENT

NAME:

JOB TITLE:

TELEPHONE NUMBER:

FAX NUMBER:

E-MAIL ADDRESS:

POSTAL ADDRESS:

Code:

SECTION D:

MARKETING DEPARTMENT

NAME:

JOB TITLE:

TELEPHONE NUMBER:

FAX NUMBER:

E-MAIL ADDRESS:

SECTION E:

OTHER INFORMATION

BUSINESS SECTOR:		Information Technology
		Agricultural
		Distribution
		Manufacturing
		Other


Where did you hear about CSS?
Your company's website:
Your current internet service provider (ISP):

CSS provides a wide range of services, some of which you might not even be aware of. Should you be interested in any of the following services, please tick the boxes below and a CSS representative will contact you regarding the service you require.

	SOFTWARE / HARDWARE SALES
	NETWORKING / CABLING
	REPAIRS OF COMPUTER PERIPHERALS (printers, monitors, hand-held scanners etc.)
	SERVER INSTALLATIONS
	DOMAIN NAME REGISTRATION
	WEBSITE AND E-MAIL HOSTING
	INTERNET CONNECTIVITY (dialup accounts, ADSL etc.)
	WEB DESIGN AND DEVELOPMENT
	CORPORATE IDENTITY / BRANDING
	GRAPHIC DESIGN (flyers, ads etc.)
	MARKETING MATERIAL (banners, bowheads etc.)


SECTION F:	PAYMENT TERMS

CREDIT TYPE:

COD (Cash on Delivery)

Please note: you will only be considered for a 30 day payment option if you spend R30,000 during every quarter (3 months). Should you fail to comply with this, your account will be changed to a COD account. For any payment options other than COD, you are required to fill in a complete credit application form which is available on request.


SECTION G:	CONFIRMATION

I Hereby bind myself to the Standard Terms and Conditions of Service of Computer Support Specialists(Pty) Ltd. (available on request) and also bind myself to the terms and conditions of payment as applicable.