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Secure
Form
We thank you for choosing our
SureDial® service to connect to the world wide web. you'll
be delighted with the service. Please fill in the form below and
submit it. we will contact you with the confirmation. This form is Secure. However as the page is in
a frame, you are not seeing the unbroken key or lock icon on
the status bar of the browser. Click here to do so, or take our word for
it. |
| Information: (All
fields should be completed.) |
| E-mail address: |
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| First name: |
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| Last name: |
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| Title: |
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| Company/Organization Name: |
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| Address: |
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| City: |
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| State: |
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| Post code: |
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| Phone: |
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| Fax: |
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| Access Plan: |
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Accounts are prepaid monthly in advance.
Prices are GST inclusive.
There is no set-up fee! | |
| Choice ID |
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| Password |
max. 8 alpha-numeric characters |
| Method of Payment |
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| Credit Card No: |
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| Expiry Date |
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| Name on Card |
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| Comments |
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| Are you also interested in any other
Service? |
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| How did you find out about us:
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| If other, please enter here: |
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| Would like to receive our
Newsletter? |
Yes
No |
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Warning: Credit card fraud is a
felony and we will aggressively prosecute anyone attempting to
misuse a credit card number. We will use all means available
to prosecute persons attempting
fraud. |