Sign-up     Dialup Internet

  ▪  Dialup Access
  ▪  ADSL Access
  ▪  Domain Name 		   
 

Dialup Internet 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:  Monthly $30.00 inc GST  O
Quarterly $75.00 inc GST O
Annual $285.00 inc GST O
50 Hours $55.00 inc GST O
100 Hours $88.00 inc GST O
User Name: ________________________
(lowercase 2-8 characters)
Password:  ________________________
(numbers and/or letters 6-8 characters)
Preferred Email Addresses: _______________@visp.com.au
(up to 5 for free) _______________@visp.com.au
_______________@visp.com.au
_______________@visp.com.au
_______________@visp.com.au
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
   
   


Copyright © 2003 VOCA Internet Service Provider.  All Rights Reserved.
Home  |  Contact Us