DialupApplication-XP/2000 SetupWin9x SetupMac PPP Setup-

P.I.P. Dialup Application

Please read the following application form
Fill in all details clearly with a black or blue pen
A seperate form is required for each account
Any inquiries please phone us on - (02) 9488-7655
When Complete fax to -
(02) 9488-7761
Service to be installed
PIP Dialup -
$2.40 / hour plan$42.90 UnlimitedPermanent Modem
Customer details
Your name or company
Address (postal)
Contact name
Work Phone
Home Phone
Login details
Current login
New login
Billing address
Address (billing)
State Postcode
Extra services required
Email 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 decleration
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