P.I.P. Dialup Application
Please read the following application form and fill in all details clearly with a black or blue pen.
A separate form is required for each account, any inquiries please phone us on - (02) 9488-7655
When Complete fax to - (02) 9488-7761
Select your plan
$2.40 / hour plan
Your name or company:
Billing Address (if different to above)
Extra Features ($P.O.A.)
Email spam/virus scanning
Domain name hosting
Credit card details
Name on card
Card type (Visa/Master/Bank) -
Agreement and declaration
I declare that:
All the information provided above is true and correct.
That I have read and agree to the Terms and Conditions and acceptable use policy of Preferred Internet Provider.
That I agree to the pricing of all services that I/we have been quoted or that appear on our current price list.
In case of a company I am authorised to make this decision on the companys' behalf.
Office use only