WebShield Internet Services

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PERSONAL DETAILS

First Name:

Last Name:

Company:
(if not for private use)

PHYSICAL ADDRESS

Street Address Line 1:

Street Address Line 2:

Suburb:

State:

Post Code:

BILLING ADDRESS (If the same as above, please leave blank)

Street Address Line 1:

Street Address Line 2:

Suburb:

State:

Post Code

CONTACT DETAILS

Day Phone No.:

Night Phone No.:

Fax:

Current e-mail Address:

BILLING/PAYMENT DETAILS

Credit Card Details:

As we are still testing our billing system we will ring you for your credit card details rather than requiring you to enter them here.

Internet Account

PERSONAL ACCOUNT DETAILS

Preferred Username:

Selected Password:
(6-12 characters)

Email Accounts (up to 5 accounts) (just letters & numbers, no .-& symbols etc)		(6-12 characters)
Preferred Address 1	Selected password 1
Preferred Address 2	Selected password 2
Preferred Address 3	Selected password 3
Preferred Address 4	Selected password 4
Preferred Address 5	Selected password 5

SELECTED PACKAGE

Safetynet:

Weave Your Own Web:

Email Plus:

SELECTED PAYMENT PLAN

Premium Dial Up ($27 per month):

Practical Dial Up ($16 per month):

Prepaid Dial Up ($1 per Hour):

Comments:

We will be treating the details you have completed on this form with confidentiality.