P.I.P. Dialup Application
Instructions
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
Login Details
$2.40 / hour plan
$42.90 Unlimited
Permanent Modem
Current Login:
New Login:
Password:
Customer Details
Your name or company:
Address (postal):
Contact name
Work Phone:
Home Phone:
Mobile Phone:
Fax:
Email:
Billing Address (if different to above)
Address (billing):
State
Postcode
Extra Features ($P.O.A.)
Email spam/virus scanning
Web hosting
Web mail
Domain name hosting
Email hosting
Credit card details
Name on card
Card type (Visa/Master/Bank) -
Card No.
Exp
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.
Signature
Position
Date
Office use only
Data (Mb's)
Base cost
Excess rate
Your name
UID