PARTNER APPLICATION FORM

1. PARTICULARS:

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i. Name of Company:

ii. Address of Company:

iii. How many years have you been operating?

iv. Number of branch outlets (if any)

2. TRADING HISTORY:

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i. Are you a licensed telecommunications service operator?

-- Select Option -- Yes No

ii. What category of license do you have?

-- Select Category -- Major network Operator (MNO) Major Internet Carrier (MIC) Others, specify...

3. PRODUCT INTERESTED IN:

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i. Which of our products are you interested in?

-- Select Product -- Lastmile Access Service (LMAS) Retail Broadband Access Service (RBAS) Other, specify...

4. REFERENCES:

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i. Name of Bank:

ii. Address of Bank:

5. PROJECTIONS:

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i. What is the minimum order that you envisage per annum?

ii. What area(s) do you intend to cover?

6. NAME AND DESIGNATION OF OFFICER COMPLETING THIS APPLICATION:

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i. Name:

ii. Designation:

iii. Tel. No:

iv. Email:

v. Date:

NB: Please, note that all information in this application will be treated as Confidential!