| Contact Name: | _______________________________________ | |
| Company Name: | _______________________________________ | |
| Postal Address: | _______________________________________ | |
| _______________________________________ | ||
| Town/Suburb: | _______________________________________ | |
| Postcode: | ___________________ | |
| Phone Number: | ______________________________________ | |
| Fax Number: | ______________________________________ | |
| Email Address: | ______________________________________ |
| Domain name: | ______________________________________ | |
| Company's ABN or ACN: | ______________________________________ | |
| Trading Name, if any: | ______________________________________ | |
| Registration number for Trading Name: | ______________________________________ |
If we are registering a domain name for you, we need payment up front. Please use the form below, or contact us for details. (Mastercard or VISA only.)
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 | ||