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WebSite Hosting Order Form  (please print, complete, sign and fax or post to us)

Date:   ________________________
Company: ________________________
First Name: ________________________
Last Name:  ________________________
Address:  ________________________
Suburb:  ________________________
State:  ________________________
Postcode:  ________________________
Contact Phone: ________________________
Contact Email: ________________________
I am 18 Years of age or older:   Yes  O No  O
I have read and agree to the Visp Internet Terms & Conditions: Yes  O No  O
Click here to view Terms & Conditions
Choose Plan Type:  Once Only Setup Fee $110.00 inc GST  O
Web & Email Hosting $375.00 inc GST 1yr O
Email Hosting $275.00 inc GST 1yr  O
Domain Registration $90.00 inc GST 2yrs O
Domain Name: ________________________
(lower case 2 - 8 characters)
IP Address for Email Forwarding:  ________________________
My preferred payment method is:  
Credit Card 
Card Number:   ________________________
Credit Card Type:  ________________________
Expiry Date: ________________________
Card Holder:     ________________________
Direct Deposit 
Adelaide Bank BSB 610-101 Acct 070659732
Signed:  ________________________
(remittance must be received prior to account activation)

 

 
 
  If you require any assistance, please email us at  accounts@visp.com.au
   
   


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