P.I.P ADSL Service Application

Instructions

Please read the following application form

Fill in all details clearly with a black or blue pen

A separate form is required for each ADSL service

Any enquiries please phone us on - (02) 9488-7655

When Complete fax to -

(02) 9488-7761

Equipment required
One of the following devices is required -
ADSL Router
ADSL Router 4port with VPN
ADSL Router 4port with VPN and Wireless
I will provide my own device

Billing address

Address (billing)

State Postcode

Credit card details

Name on card

Card type (Visa/Master/Bank) -

Card No. Exp

Phone number for this service

The current phone number of the phone line
that you are converting to ADSL

Agreement and declaration
I declare that:
All the information provided above is true and correct
That I have read and agree to the ADSL Terms and Conditions and Acceptable Use Policy of Preferred Internet Providers ADSL Service
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