Dial Up Connection Application Form
Please print this out, fill in the form and then fax or mail it back to us with your payment

Company Name (if applicable):___________________________________ ABN:___________________
Your Name:__________________________________________________________
Suburb:________________________ State:______________ Postcode:______________
Existing e-mail, if any:_____________________________________________
Phone(home):________________ Phone(work):________________ Fax:_________________
Login Name (1st Pref.): (2nd Pref.):

Please select the service required:

D1 - Hourly Rate Account, $5/mth for 10 hrs, extra hours in the month are $1/hr

D2 - Flat Rate Account, $25/mth or $66/qtr or $250/yr.

*** For D1, you will pay $25 to create a pre-paid balance.
When this balance drops below $15, you will pay another $25 to top up.
*** For D2, ANS will bill you by the quarter unless you instruct us otherwise.
*** User pays the telephone calls to use the service.
*** Other conditions apply. Please read the details at http://www.ans.com.au/terms.html

Please subscribe me to the above selected Account. I have read and accept the terms and conditions for it. I know that they are avaliable on request and are posted on the Internet.

Applicant Signature:______________________________ Date:__________________

For speedy processing, pay by credit card and fill in the details below.
We accept payment by cheque or money order.
But the service will only start after we receive your payment.

Please charge my credit card with details below for the first payment and charge the same for all on-going charges in the future.

AMEX Bankcard Master Card Visa Card

Card Number:

Exp. date:____________ Name on the card:_______________________________________