Nashua Mobile Internet Application Form:

Fill in the fields below. A consultant will get in touch shortly.

Step 1:
                    Customer Details:
Existing Client:    
If Yes, State Acc No.: If Yes, State Cell No.:
Contact Person: **ID No.:
Work Phone No.: Home Phone No.:
Fax No.: Cell No.:
Physical Address: Postal Address:
Physical Code: Postal Code:
Email Address:    
Employer Name: Occupation:
Employer Address: Postal Code:
Gross Monthly Income: Duration of Employment:
                    Bank Details:
Method of Payment:  
Name of Account Holder: Bank:
Branch Code: Branch Name:
Type of Account: Bank Account No.:
Credit Card Type:    
Credit Card Number: Credit Expiry Date:
                    Services Required:
Internet Connectivity: Hosting:
Email Hosting: Fax to Email / Email to Fax:
Domain Registration: Search Engine Submissions:

*Please Note: Please supply a copy of VAT Registration document
** Please Note: Please supply a copy of ID Book.

By Submitting this form I/We confirm that the above mentioned information is true and correct and that I/We have read and agreed to Nashua Internet Terms and Conditions below:


I Agree to the Nashua Mobile Terms & Conditions