| Name: | ______________________________ | |
| Postal Address : | ______________________________ | |
| ______________________________ | ||
| Town : | ______________________________ | |
| Postcode : | __________ | |
| Phone Number : | ____________________ | |
| Fax Number : | ____________________ |
Preferred User Name : Lower case characters, a to z only. Minimum
of 3, Maximum of 8 characters.
First Choice : __ __ __ __ __ __ __ __ Second Choice : __ __
__ __ __ __ __ __
The Username becomes the first part of your e-mail address, ie, username@riverland.net.au
Password : Passwords are case sensitive. They must be entered exactly
as shown on this application or they will not work. A minimum of 5 and a maximum
of 8 characters, A to Z, a to z and 0 to 9 can be used. A mixture of upper
and lower case letters and numbers may be used. Try to choose a password that
nobody would guess, but which you can remember.
PASSWORD : __ __ __ __ __ __ __ __
Cheque / Money order enclosed for $________ or I Hereby authorise Riverland Internet to debit my credit card for the amount of $ ________
Cardholder Name : ____________________________
Cardholders Signature : ________________________
Credit Card Number : [ __ __ __ __ ] [ __ __ __ __ ] [ __ __ __ __
] [ __ __ __ __ ]
Expiry Date : __ __ / __ __
Verification Code : __ __ __ (the last 3 digits from the signature area on the back of the card)
| This form can be faxed to: (08) 8586 6999 | or posted to: | Riverland Internet |
| PO Box 832 | ||
| Renmark, South Australia 5341 |