Greenbank Net Dial-Up Application Gold Coast

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. Please tick operating system
 

Windows 95

  

Windows NT

  

Windows 3.X

  

Macintosh 7.X or 8.X

  

Other

4. Connection Details

Login Name

(1st Choice)

Login name must be between 3 and 8 Characters. E.g. John Smith might choose jsmith@greenbank.net.au or johns@greenbank.net.au Lower case can only be used.

Login Name

(2nd Choice)

Please indicate a 2nd choice for your login name in case your first choice is not available. Lower case can only be used.

Password

Passwords must be between 6-8 characters and can include numbers E.g. star123. Lower case can only be used.

5. Additional Mail Boxes

User Name

Email Address

Password

 

   

Additional Mailboxes can be purchased at $10.00 per month and extra Web space at $5.00 per 2 meg. Please advise on a separate piece of paper user names, email addresses and passwords if you require additional mailboxes or Web space.

6. Payment Details

 

Cheque

  

Bank Card

  

Visa Card

  

Master Card

Name on Card

Card Number

---

Expiry Date

/

Total + $5 POP fee
$

Please note: For users of either the Greenbank POP or the Burpengary POP there is a $5/month remote POP fee

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

 

Signature: ______________________________________ Date: ________________

Please tick appropriate box

Greenbank Standard
Greenbank Super
Greenbank Plus

 

$30

100 Meg Data Free. (1 month)

  

$50

200 meg data free(1 month)

  

$85

300 Meg data free (1 month)

 

$176

100 meg Data. (6 months)

  

$294

200 meg data free (6 months)

  

$382

300 Meg data free (6 month)

 

$342

100 meg data. (12 months)

  

$570

200 meg data free (12 months)

  

$741

300 Meg data free (12 month)


Please note: Add $5.00 Per Month for the POP fee to the three plans

Casual Access plan $2.50 Per hour with a minimum charge of $5.00 Per Month
Vampire Plan $0.50 Per Hour / $0.25 Per Meg / Time you may use 10pm to 6am

Accounts will not be created 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