P.I.P Managed Service Application
Instructions
Please read the following application form.
Fill in all details clearly with a black or blue pen.
Any enquiries please phone us on - (02) 9488-7655
When Complete fax to
(02) 9488-7761
Email details
Email Address
Password
Customer details
Your name or company
Address
Contact name
Work Phone
Home Phone
Fax
Email
Service to be installed
Exchange Corporate Web Access
Exchange Hosted STD Plus
Managed Back Office Pro
Managed Back Office Pro with Exchange
Data Required per user
200MB
500MB
1000MB
2000MB
Billing address
Address (If different from company location)
State
Postcode
Credit card details
Name on card
Card type (Visa/Master) -
Card No.
Exp
Agreement and declaration
I declare that:
All the information provided above is true and correct.
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
