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 Login Details
$2.40 / hour plan
$42.90 Unlimited
Permanent Modem

Current Login:
New Login:     
Customer Details
Your name or company:
Address (postal):

Contact name

Work Phone:

Home Phone:

Mobile Phone:


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