Greenbank Net Co-Hosting Application

Telephone: (07) 3876 9044 Facsimile: (07) 3876 9033 P.O.Box 2079 Graceville 4075

1. Client Details

Name

  

Address

 

P/C

Home Phone Number

 

Work Phone Number

 

Mobile Number

 

Work Fax Number

 

Date of Birth

 

Drivers Licence No:

 

2. Where did you hear about Greenbank Net?
 

Internet

  

Advertising

  

Word of Mouth

  

Direct Mail

  

Seminar

  

Other_________________

3. Connection Details

Password:

Greenbank.Net Requires Root / Administrator Password To the Co-Hosted Machine.

4. Payment Details

 

Cheque

  

Bank Card

  

Visa Card

  

Master Card

Name on Card

Card Number

---

Expiry Date

/

Total

$ 40.00 / Month = $
Data 25c/Meg
Minimum 500 Meg
Setup Fee $50
Installation of OS (Optional) $50

Agreement: I have read, understood, and hereby agree to Greenbank.net's "Terms and Conditions" as amended.

 

Signature: ______________________________________ Date:

Accounts will be charged in advance for the month administration fees.

Co-hosting machines will not be activated until payment in advance in full is received. Subsequently, credit cards will be debited in advance until terminated by notification in writing. Submission to Greenbank.net of this form constitutes a binding contract subject to Greenbank.net’s "Terms and Conditions" as amended from time to time. Current Terms and conditions can be found on Greenbank.net’s web site at – http://www.greenbank.net.au/terms.html