Please print this form, then send it to the fax or address below.
We will contact you when we receive it. Sorry, we do need a written signature.
| Contact Details |
| Name : | ______________________________ |
| Address : | ______________________________ |
| ______________________________ | |
| Town : | ______________________________ |
| Email address : | ______________________________ |
| Phone Number : | ____________________ |
| Fax Number : | ____________________ |
| Location of required ADSL Service |
| Street Address : | __________________________ |
| Town : | __________________________ |
| Phone Number : | ____________________ |
| Existing Account with Riverland Internet |
If you already have an account with
Riverland Internet, what is the username: __ __ __ __ __ __ __ __
(If you're a new customer, what would you like it to be?)
| ADSL Account Required - Plan information available at http://www.riverland.net.au/text/adsl-price.htm#plans |
| Line speed | Medium | Full size |
| 256/64 | 1 GB, $33 | 20 GB, $44 |
| 512/128 | 3 GB, $44 | 20 GB, $55 |
| 1500/256 | 10 GB, $55 | 25 GB, $77 |
| 8M/384 | 5 GB, $82.50 | 25 GB, $93.50 |
Other plan type: ________________________________
The Line Setup fee is payable in advance.
Cheque / Money Order enclosed for $130.00Cardholder Name : ____________________________
Card Type :
Bankcard
Master Card
Visa
Cardholders Signature : ________________________
Credit Card Number : [ __ __ __ __ ] [ __ __ __ __ ] [ __ __ __ __
] [ __ __ __ __ ]
Expiry Date : __ __ / __ __
Verification Code : __ __ __ (the last 3 digits from the signature area on the back of the card)
| Terms and Conditions |
By signing here, I declare that I have read, understood and agree to the conditions and charges as set out in the standard "Terms and Conditions" and the "Fees and Charges" Sections.
I have also read, understood and agree to the additional conditions set out in the "Additional Terms and Conditions for ADSL".
Please supply the selected ADSL service on the phone line listed. I understand that monthly billing will commence when the line setup is complete.
SIGNATURE : _________________________ DATE : ____ / ____ / ____
| Please fax this form to: (08) 8586 6999 | or deliver it to: | Riverland Internet |
| PO Box 832 | ||
| Renmark, South Australia 5341 |