COASTHOST ORDER FORM
Please read our Billing Policy for payment and renewal information. Click here to print this form -------------------------------------------------------------------------------- COASTHOST PO Box 391 Suite 1, 29 West St Burleigh Heads Burleigh Heads, Qld Australia. 4220 Qld. Australia 4220 Phone: Aust. Customers: (07) 5576 2751, International Customers: +61 7 5576 2751 Fax: Aust. Customers: (07) 5538 7571, International Customers: +61 7 5538 7571 Email: sales@coasthost.net.au, support@coasthost.net.au, billing@coasthost.net.au -------------------------------------------------------------------------------- ORDER DATE: -------------------------------------------------------------------------------- ORDER INFORMATION Required fields are marked with an asterisk * Mark a tick or [X] in the brackets for your selection -------------------------------------------------------------------------------- * Domain Name: www.______________________________________________ [ ] - This is a new domain and I wish to register it with Coasthost. [ ] - I already own this domain name or will register it myself. -------------------------------------------------------------------------------- Company Name:_________________________________________________________________ ACN/ABN/BN:___________________________________________________________________ A business number is essential if registering a ".au" or if placing a purchase order. -------------------------------------------------------------------------------- * Email:________________________________________________________________________ This e-mail address must not include the domain name you wish to host with Coasthost. Your setup account details will be emailed to this address. -------------------------------------------------------------------------------- * Full Name:____________________________________________________________________ * Address:______________________________________________________________________ * City:_________________________________________________________________________ * State:________________________________________________________________________ * Postcode:_____________________________________________________________________ * Country:______________________________________________________________________ * Phone:________________________________________________________________________ Fax:__________________________________________________________________________ -------------------------------------------------------------------------------- POSTAL ADDRESS (if different) -------------------------------------------------------------------------------- Address:______________________________________________________________________ City:_________________________________________________________________________ State:________________________________________________________________________ Postcode:_____________________________________________________________________ Country:______________________________________________________________________ Phone:________________________________________________________________________ Fax:__________________________________________________________________________ note: Prices below include GST. WEB HOSTING PLANS -------------------------------------------------------------------------------- 1. Starter: 100MB disk / 10GB transfer / 10 email accounts [ ] 12 months : AU$178.80 @ AU$14.90 per month [ ] 3 months : AU$49.17 @ AU$16.39 per month 2. Pro: 500MB disk / 20GB transfer / 50 email accounts [ ] 12 months : AU$298.80 @ AU$24.90 per month [ ] 3 months : AU$82.17 @ AU$27.39 per month DOMAIN REGISTRATION (inc.gst) -------------------------------------------------------------------------------- [ ] .com.au, .net.au AU$88.00 2 years [ ] .com, .net, .org, .biz AU$33.00 1 year SECURE SSL CERTIFICATE (inc.gst) -------------------------------------------------------------------------------- [ ] SSL Certificate AU$199.00 1 year PAYMENT METHOD -------------------------------------------------------------------------------- [ ] Credit Card - We welcome Visa, Mastercard, Bankcard, Diners and AMEX -Account Number:...................................... -Expiry Date:......................................... -Name on card:........................................ -CVV2 Number:......................................... (CVV2 is a 3-4 digit number from the back right of the card, or on the front for AMEX) [ ] Bank Transfer BSB: 484-799, A/c: 044920694, REF: use domain name [ ] Cheque or [ ] Cash Payment is required before registration of domain names or SSL certificates. -------------------------------------------------------------------------------- DECLARATION I hereby declare that: 1. I am the customer and/or authorised agent of the customer. 2. I have read and agree to the Coasthost Terms and Conditions as presented on the www.coasthost.net.au/policy_terms.html web site. 3. All information contained on this document is to the best of my knowledge true and correct. Signature:........................................ Date:................... Name:........................................................................... -------------------------------------------------------------------------------- OFFICE USE ONLY Received By:....................................... Time:.................. Signature of Officer:.............................. Date:..................
WEB HOSTING &/or DOMAIN NAME REGISTRATION