| • To register, please
complete the form below. |
| 1. Hosting Services |
|
| Service Plan |
|
| Preferred User Name (1) |
|
| Preferred User Name (2) |
|
| Preferred Password |
|
| Have you used the Internet
before?
Yes
No |
| |
| 2. Personal Details |
|
| First Name |
|
| Last name |
|
| Address |
|
| City/Suburb |
|
| State |
|
| Post Code |
|
| Home Tel |
|
| Work Tel |
|
| Fax |
|
| Email |
|
If you wish to register a domain name, please fill in sections 3 & 4.
Otherwise, please go to section 5.
|
| 3. Company Details |
|
| Legal Name of the Organisation |
|
| Australian Business Number
(ABN) |
|
| Or |
|
| Registered Business Name |
|
| Business Registration Number |
|
| State of Business Registration |
|
4. Domain Information |
|
| Preferred Domain Name (1) |
|
| Preferred Domain Name (2) |
|
| Preferred ftp Password |
|
5. Payment Method (Select one) |
|
By cheque or money order to Knowledge by Design |
| Cheque/Order no. |
|
| Date sent |
|
By direct deposit to Bank
OZtell (Account Number: 11 9656)
Westpac Banking Corporation
Haymarket Branch (Branch Number: 032 005)
Please fax to 02 9212 5727 or send a copy of the bank receipt to confirm
transaction |
| Deposit Date |
|
| Bank |
|
| Branch |
|
By Visa, Master or Bank Card |
| Name of Card Holder |
|
| Card Number |
|
| Expiry Date |
|
Comments (optional) |
|
| |
Please click the Submit button below to submit your registration form.
Click the Reset button to clear the text fields.
|
| |
|
| |
Mail our customer
support for more information.
|
