Domain Hosting 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):________________________________________________
ACN / ABN / BRN________________________________ For BRN, State of Reg:____________
Your Name:______________________________________________________________
Address:__________________________________________________________
Suburb:________________________ State:______________ Postcode:______________
Existing e-mail, if any:_____________________________________________
Phone (home):________________ Phone (work):________________ Fax:_________________
Login Name (1st Pref.): (2nd Pref.):
Password:

Domain Name: _______________________________
Please select the service required:

W1 - Domain email only, $60/yr, $60 setup

W2 - Domain general hosting, $25/mth or $22/mth if you use our dialup or adsl service.

*** For W2, payments are made on a quarterly basis, i.e. $75 (or $66) a quarter.
*** You are responsible for the registration and renewal or your domain names.
*** 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 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:_______________________________________

Signature:______________________________________________________