ipNX Nigeria Limited

RESELLERS

Resellers

CONTRACT REGISTRATION FORM (DEALERS FORM)

FILL FORM BELOW

Dealer's Name

Dealer's Code

Transaction Reference

Name of Subscriber (Corporate Name for Company/Business)

Surname

Middle Name

First Name

Contact Person

Surname

Middle Name

First Name

Nature of Business (e.g. Stock-broking, archy firm, travel agency e.t.c)

Service Plan and Monthly Subscription Cost (5% VAT Inclusive): Circle or Tick One

Family	Family+	Home Office	Professional	Small Business	Small Business+
N 6,300	N 9,450	N 15,750	N 21,000	N 28,350	N 47,250

Business/Residential Address

Installation Address

ESN			Customer ID


Email 1			Email2


Phone 1 (GSM)			Phone 2


DECLARATION
From: Dealer’s Authorized Person To: ipNX Nigeria Limited We hereby apply for the iwireless broadband internet service as per details furnished above. We confirm that the subscriber’s information has been accurately and completely supplied. We confirm that the subscriber has been provided with the company stipulated terms and conditions (hereby replicated). We confirm that the information furnished above is correct. In the event that the information is found to be incorrect, ipNX Nigeria Limited shall have the right to take recourse and we shall have no claims whatsoever on or against ipNX Nigeria Limited.

Agree to above declaration

Agree that customer has completed & signed a form that contains the recommended end user agreement, in own (customer’s) hand