All prices quoted include 10% GST
Internet Services Application Form
Fax to: (03) 9686 7888 or Mail to:
InterDomain Pty Ltd 71-73 Thistlethwaite Street South Melbourne 3205 Victoria

ABN 16 070 386 855
New account Alteration to existing account
Dial-up Internet Access
ID Home Light ID Casual ID Home Regular ID Business ID Permanent
Domain Registration and/orMaintenance
(Hosting, redelegation and registration services will be charged to a credit card automatically each month.)
Preferred domain name
(e.g. yourcompanyname.com.au)
Business/Company Name
ABN/ABRN
Hosting
ID Access-Based ID Starter Site ID Economy Site ID Commerce Site ID Professional Site
Administrative contact
(ie the person InterDomain should call if we have questions)
Title Mr Mrs Miss Ms Dr Prof
First Name
Surname
Business/Company Name
ABN/ABRN
Directors 1 (if incorporated)
Directors 2 (if incorporated)
Address
Address (continued)
Suburb
Postcode
ABN / ABRN
Preferred dial-up user name
(two to eight lower case characters and digits)
Fax
Telephone Mobile
Telephone Home
Telephone Work
Computer Platform Windows Macintosh Other(specify)
   
Payment details MasterCard Visa Bankcard Amex Diners
Cardholder’s name
Card no.
Expiry date
I am authorised by the applicant entity to make this declaration.
I hereby authorise the initial and ongoing charges to be debited to the above credit card account each month in payment for Internet services according to the pricing structure published online until this arrangement is cancelled in writing (including electronic message) by either myself or InterDomain Pty Ltd. I accept the terms and conditions of the Agreement for provision of Internet service of InterDomain Pty Ltd which agreement prohibits use of the Internet for illegal purposes and limits the liability of InterDomain Pty Ltd.

Signed by cardholder (for fax or mail applications only)


_________________________________ Date __________

For online applications:

I have read and accept the terms and conditions of the Agreement.