Internet & Value
Added Services Order/Sign up Form
Thank you for choosing ITClick. Please take some time to
fill and click on "submit" to send this form by email.
Service will be activated subject to the verification
process and provisions outlined in ITClick Terms of Service
(TOS). You will be sent a hard copy of this form and you are
required to sign and return prior to activation.
Service Requirement
Organization Contact Person or End User
Title
First Name
Middle Name
Last Name
GSM Phone
Other Phone
Email address
For Commercial [Cybercafés/ISPs)
Customers, CAC RC, NCC Reg., EFCC Reg and photocopies of
utility bills arerequired as mandated by EFCC . For all
other organizations, only CAC RC No. and photocopies of
utility bills arerequired.
Personal Contact Information & Billing Address:
Passport
Address
City
State
Install CPE at same address
above? Yes
No
Company Information
& Billing Address:
NCC License No.:
EFCC Reg. No.:
CAC RC. No.:
Company
Address
City
State
Install CPE at same address
above? Yes
No
Access information
User ID MUST be in lower case, no spaces, no punctuation and
12 characters max. Password will be automatically generated
and sent to the email address specified above. You can
change your password afterwards. Ensure you provide accurate
email address as login details will be sent to this address
User ID
How did you hear
about us?
Referrer ID
Select Product
What Date Shall we
install
your CPE
What Date should we
activate your account?
When My Service
Expires
Public IP Address
requirements
(Only for Organization: 5 or
more Public IP address requires completion of `IPAddress
Justification Form' and subsequent ITClick approval)
Static Public IP
Addresses
CPE Delivery and
Installation Address:
You specified that CPE will be
installed at a location different from the address you
specified on page 1.Please indicate where CPE will be
installed and service delivered
By Checking "I Accept" below,
I/We hereby elect to subscribe to ITClick services and have
read, understand, andagree to be bound by ITClick's Terms of
Service (TOS) and Acceptable Use Policy (AUP).
